BACKGROUND Referral notes are the main communication method between primary physicians and hospital physicians. Therefore, the written referral, has great importance in explaining the patient's condition or complaint, and the additional steps or actions that may be required for their complete evaluation and diagnosis. In this research we evaluated the main reasons for child referral to the hospital and, whether both the hospital physician and the child's parents understood those reasons correctly. METHODS All the children referred to the ED during four weeks in July 2013 were included. For all cases with referral notes three questionnaires were presented: One to the hospital physician, one to the child's parents and a third, (via phone conversation), to the referring physician. RESULTS At least two questionnaires were completed for each of the 261 cases. When primary physicians' original goals were compared with the hospital physicians' interpretation, only 33.7% of cases were fully matched, in 24.8% of cases there was a partial match and in 41.6% there was no match at all. When primary physicians' original goals were compared with the parents' understanding only 35.5% showed that they were fully matched, 30.3% showed partial match and 34.2% show no match at all. When evaluating primary physicians' intention with hospital physicians' interpretation, we found that during on-call hours the probability for a match was lower. Matching was higher for more experienced primary physicians. CONCLUSIONS This research reinforces the impression of many hospital physicians of misunderstanding referral goals. Over 65% of referrals were partially or totally misunderstood. These findings are of importance when evaluating a sick child, since the community doctor usually has a greater acquaintance with the patient's condition gathered over the years or during an acute illness.