Medical errors often occur when care is transitioned from one physician to another. Liability is created when time-sensitive information and necessary follow-up treatment slip through the cracks. Therefore, it is important to have a clear, methodic process in place to ensure continuity of care when a patient is referred to a specialist or on-going care is transferred to another physician.
Clear communication and factual, descriptive documentation are critical components in the referral/ transfer process. Lack of communication in the hand-off process can result in lost information or false assumptions and confusion, resulting in increased liability. In time-sensitive situations, it is essential to have direct physician-to-physician communication -- or staff on their behalf -- to ensure transfer of critical patient medical status in addition to written documentation and orders.
Documentation is a very important aspect of the referral/transfer process, and is as important as the communication itself. Documentation may be a narrative summary or a standardized checklist. A checklist may provide a template for the type of information that should be communicated on referral or transfer.
Minimum critical patient medical status to communicate includes:
- Diagnosis, problem list, current treatments
- Test results, pending labs/diagnostics, current treatments
- Medications, allergies
- Consents obtained and needed
Additional information that may be useful:
- History and summary of significant findings
- Patient and family education
- Patient registration/fact sheet information
- Telephone conversations, meetings, or any communication between physicians
- Physician and family/other contact information
Attention to detail during the referral/transfer process by physicians and their staff may prevent errors and enhance patient care, follow-up, and safety as care transitions to the next provider.
Authored by
Jackie Gellis, MHA, RN
CAP Senior Risk Management & Patient Safety Specialist
If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.