Chapter 12: Communication
Katie Baker
When working with a patient, you may find that their condition is being managed by outpatient specialists and primary care physicians or even inpatient providers such as anesthesiologists, surgeons, and hospitalists. All these professionals, as well as anyone providing allied health services such as occupational or physical therapy, dietician services and counseling, comprise the patient’s healthcare team.
Prompt communication between team members is essential for optimal patient care. Most communication will occur in writing, either through electronic charting and referral systems or via faxed and mailed correspondence, but occasionally a phone call will be necessary to communicate information about patient treatments, test results, or concerns in a timely manner. As mentioned earlier in this chapter, professional manners during communication with other providers is a must. Although it may be helpful to provide some context for the referral, including information about patient resistance to treatment, refrain from complaining about patients or other providers when communicating with other provider offices.
Writing Referrals
Generally speaking, a written referral will include medical charting and a cover letter that summarizes the patient’s situation. If the referral is brand-new, this can include the history of the present illness and treatments thus far. If you are communicating with another provider about ongoing treatment, it is typically expected that only new information will be included as well as an evaluation of the patient’s current condition and response to treatment. Many larger facilities will require a specific referral form to be completed by a provider’s staff and sent in along with the referral letter and documentation from the chart, including information from the patient intake forms and their insurance information.
A Look at Referrals
A sample referral letter can be seen below that provides all of the relevant information for a specialist provider.
(Referring Provider Contact Information)
Re: Patient last name, Patient first name
Date:
Dear Dr. ABC
I would like to refer (patient name) to you for further evaluation of (diagnosis and ICD code).
Mx. 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/procedure notes relating to this condition. Thank you for your timely and considerate care of this patient. Please send copies of patient chart notes to our office.
(closing),
Referring Provider Name and Credentials
(physician office contact information)
Office staff will frequently be assigned the duties of ensuring that referrals are received and many electronic health record systems offer form letters for this purpose. Patients should be encouraged to expect a wait of at least a week for non-urgent referrals to be received and processed, after which time, if the referred provider’s office does not reach out to them for scheduling, they can be encouraged to call directly.
A letter to a new provider or specialist explaining a patients history, labs and exams undertaken and their results and any previous treatments to allow for further evaluation, diagnosis, or treatment of specific medical conditions.