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Risk Factors with Patient Referral and Transfer

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.

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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.