Medical errors often occur when patients are transitioned from one physician to another. Liability is created when time-sensitive information and necessary follow-up treatment slip through the cracks. It is therefore important to have a clear, organized process in place to ensure continuity of care when a patient is referred to a specialist, or care of a patient is transferred to another physician.
Solid communication and good documentation are critical components in your referral/transfer process. Lack of communication can result in lost information, false assumptions, and confusion, resulting in increased liability. It is essential that you have direct person to person communication between the physicians, or staff on behalf of the physicians, when there is a time-sensitive referral to a specialist, or with the covering/on-call physician.
Documentation is also a very important aspect of your referral/transfer process. Documentation can be a narrative summary or a standardized checklist. A checklist can be used as a template for the type of information which should be communicated on referral or transfer. The minimum information which should be communicated is:
- Diagnosis, problem list
- Test results, current treatments
- Medications, allergies
- Pending labs/diagnostics with contact information
Other information which could be provided is:
- History and summary of significant findings
- Patient and family education
- Consents and patient registration/fact sheet information
- Telephone conversations or meetings between physicians
- Physician and family/other contact information
By giving appropriate attention to detail, physicians and their staff will enhance patient care, prevent errors, and reduce the chance of lawsuits.
Authored by
Mari Renna, PhD, RN
CAP Risk Management & Patient Safety Department
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