12.3 Sharing Information With Other Providers
Katie Baker
When working with a patient, you may find that their condition is managed by a team of healthcare professionals, including outpatient specialists, primary care physicians, and inpatient providers such as anesthesiologists, surgeons, and hospitalists. Allied health professionals, such as occupational or physical therapists, dietitians, and counselors, are also important members of the healthcare team.
Effective and timely communication among team members is essential for optimal patient care. While most communication will occur in writing, through electronic charting systems, referral platforms, or via fax and mail, sometimes a phone call is necessary to relay urgent information about patient treatments, test results, or concerns. As discussed earlier in this chapter, maintaining professionalism is crucial when communicating with other providers. Although it may be helpful to include some context in a referral (such as patient resistance to treatment), it is important to avoid complaining about patients or other providers in your communication.
Writing Referrals
In general, a written referral will include medical charting and a cover letter summarizing the patient’s situation. For new referrals, the letter should include the history of the present illness and treatments undertaken thus far. For ongoing treatment, it is expected that the referral will focus on new information, an evaluation of the patient’s current condition, and their response to treatment. Many larger facilities may require a specific referral form, which should be completed by the provider’s staff and submitted with the referral letter and relevant chart documentation, including intake forms and insurance details.
A Look at Referrals
Below is a sample referral letter that provides the necessary information for a specialist provider:
[Referring Provider Contact Information]
Date:
Re: [Patient Last Name, Patient First Name]
Dear [Dr. Name],
I would like to refer [patient name] to you for further evaluation of [diagnosis and ICD code].
[Patient Last Name] came to me initially on [date of first visit] for [symptoms] and was diagnosed with [diagnosis], based on physical exam findings and [any relevant tests/procedures]. I have been treating them with [treatments including prescription medication, any procedures or therapies] and have not seen the improvement we would expect.
I am enclosing visit summaries for all relevant visits since [date of first visit] and lab results, imaging, and procedure notes related to this condition. Thank you for your timely and considerate care of this patient. Please send copies of the patient ‘s chart notes to our office.
Sincerely,
[Referring Provider Name and Credentials]
[Physician Office Contact Information]
Office staff are often responsible for ensuring that referrals are received, and many electronic health record systems provide form letters to streamline this process. Patients should be