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Standards for general practices (4th edition)

including Interpretive guide for Aboriginal and Torres Strait Islander health services

Standard 1.6 Coordination of care

Our practice engages with a range of relevant health and community services to improve patient care.

Criterion 1.6.2

Referral documents

Our referral documents to other healthcare providers contain sufficient information to facilitate optimal patient care.

Indicators

► A. Our practice can demonstrate that referral letters are legible, contain at least three approved patient identifiers, state the purpose of the referral and where appropriate:

  • are on appropriate practice stationery
  • include relevant history, examination findings and current management
  • include a list of known allergies, adverse drug reactions and current medicines
  • the doctor making the referral is appropriately identified
  • the healthcare setting from which the referral has been made is identified
  • the healthcare setting to which the referral is being made is identified
  • if known, the healthcare provider to whom the referral is being made is identified
  • if the referral is transmitted electronically then it is done in a secure manner
  • a copy of referral documents is retained in the patient health record.

Explanation

Key points

  • Practices need to ensure enough information is provided on referrals to ensure that:
    • the correct patient is referred
    • the person to whom the patient is referred receives sufficient relevant information to manage the patient
    • patient confidentiality is preserved
    • ‘known allergy’ means a hypersensitivity reaction to a medicine or other substance that is made known to a GP
    • ‘adverse drug reaction’ means harm that results from a medicine
    • this criterion cross references to Criterion 3.1.4 Patient identification.

Patient identification

The correct identification of patients is crucial in referring patients to ensure the right patient receives the right treatment. This issue is covered in more detail in Criterion 3.1.4 Patient identification.

Approved patient identifiers include:

  • name
  • address
  • date of birth
  • gender
  • patient record number where it exists.

Sufficient information

Referral documents are a key tool in integrating the care of patients with external healthcare providers and therefore need to be legible (preferably typed) and contain sufficient information to allow the other healthcare provider to provide care to the patient, without disclosing sensitive patient health information that is not relevant to the referral (eg. inclusion of sensitive material such as a previous termination of pregnancy or STI would be unlikely to be of clinical relevance to a local physiotherapist, but would be important in an obstetric or gynaecological referral). Most of the information needed for a referral may be found in the patient’s health summary; many practices routinely incorporate a copy of the patient health summary into a referral letter or attach the summary as a separate document.

Disclosure of patient information

Patients need to be aware that their patient health information is being disclosed in these referral documents. Practices may consider whether patients should be given the opportunity to read the content of the referral letter before it is forwarded to another care provider.

Referrals sent electronically

Unless the patient has provided informed consent to do otherwise, referrals forwarded by email should be encrypted and the practice must comply with standards for the secure transmission of health information to avoid a breach of patient confidentiality (see Criterion 4.2.2 Information security).

Unique patient identifiers

The National E-Health Transition Authority is developing a system of unique patient identifiers for patients, as well as individual healthcare providers and organisations. Unique patient identifiers will support the electronic transfer of information and where available should be used to complement the three required patient identifiers. These identifiers will facilitate the accurate and secure transfer of patient health information between the different areas that provide care to an individual patient.

Telephone referrals

In the case of an emergency or other unusual circumstance, a telephone referral may be appropriate. A telephone referral needs to be documented in the patient’s health record.

Keep copies of referrals

For both medicolegal and clinical reasons, practices need to keep copies of important (non routine) referral letters (ie. new referrals or those for serious conditions) in the patient’s health record. While the significance of individual letters is at the discretion of the GP, practices where no referral letters have been retained would not meet this criterion.

Practice software

The RACGP is aware that due to the limitations of some software which groups allergies and adverse drug reactions together, some practices may be unable to keep separate lists of known allergies and adverse drug reactions for a patient.

Services providing care outside normal opening hours

Services that provide care outside normal opening hours need to forward a copy of referral letters to the patient’s regular GP/general practice.

Standard 1.6 Coordination of care

Our practice engages with a range of relevant health and community services to improve patient care.

Criterion 1.6.2

Referral documents

Our referral documents to other healthcare providers contain sufficient information to facilitate optimal patient care.

In a nutshell

A good referral provides adequate patient information for the safe and effective care of your patients by other service providers. Referral letters need to contain at least three approved patient identifiers, the purpose of the referral and relevant health information. Your communication of health information should be secure, and patients need to be informed of the contents of referral documents.

Key team members

  • Health service doctors

Key organisational functions

  • Proforma referral letter
  • Referral protocols
  • Patient confidentiality and privacy policy

Indicators and what they mean

Table 1.13 explains each of the indicators for this criterion. Refer to Criterion 1.6.2 Referral documents of the Standards for general practices for explanations of some of the concepts referred to in this criterion. 

Table 1.13 Criterion 1.6.2 Referral documents
IndicatorWhat this means and handy hints
▶ A. Our practice can demonstrate that referral letters are legible, contain at least three approved patient identifiers, state the purpose of the referral and where appropriate:
  • are on appropriate practice stationery
  • include relevant history, examination findings and current management
  • include a list of known allergies, adverse drug reactions and current medications
  • the doctor making the referral is appropriately identified
  • the healthcare setting from which the referral has been made is identified
  • the healthcare setting to which the referral is being made is identified
  • if known, the healthcare provider to whom the referral is being made is identified
  • if the referral is transmitted electronically then it is done in a secure manner
  • a copy of the referral is retained in the patient health record.
Referral letters are a key tool in integrating your patient care with external healthcare providers. A referral letter should contain information that allows other healthcare providers to make appropriate medical and other decisions. It needs to be legible, printed or written on appropriate practice stationery (including letterhead, address and contact details) and to contain sufficient information, including:
  • at least three patient identifiers
  • relevant history, examination findings and current management
  • a list of known allergies, adverse drug reactions and current medications
  • the identity of the referring doctor
  • the healthcare setting from which the referral is made (for example, a general practice or an emergency room)
  • the healthcare setting to which the referral is made (for example, the emergency ward in hospital or a specialist consultancy)
  • the healthcare provider, where known, including the identity of the relevant practitioner (name of specialist)
  • any culturally appropriate information to facilitate culturally safe practices by other health service providers (for example, the need for an interpreter).
If sent electronically, a referral should be encrypted, unless patients have provided informed consent for it to be sent otherwise. In any event, it is important that your service protects patient confidentiality.

You should keep a copy of the referral letter in patient health records.

Only clinically relevant patient health information should be provided in referral letters. Relevant means information that is required by healthcare practitioners in the diagnosis and treatment of patients. For example, a previous termination of pregnancy or an STI would be unlikely to be of clinical relevance to a physiotherapist, but would be important in an obstetric or gynaecological referral.

It is important to consider your patients’ informed consent and your protection of patient confidentiality when writing referral letters. This consideration covers both the information to be included, and the way the information is transmitted. It means you should inform patients of the contents of the referral letter and, where appropriate, offer them the opportunity to read the contents or provide them with a copy. Where a referral letter is sent electronically, you need to ensure the email is encrypted, and that it complies with standards for secure transmission of patient health information (see Criterion 4.2.2 Information security).

Where telephone referrals have been made, you need to document them in patient health records. You should also record here other relevant information, such as the time and date of the referral and any patient health information provided to other health service providers.

Out-of-hours health services should forward a copy of any referral letters they may initiate to the health service provider to whom they are contracted.

Case study

Below is a description of the ways in which an Aboriginal community controlled health service can ensure appropriate referrals to other healthcare providers for its patients and community. Not all of these good practices are required by the Standards, but they illustrate the many practical and creative things that ACCHSs can do to ensure they deliver services of high safety and quality to their community.

The health service’s clinical software package provides standard referral document templates that include the service name, address and contact details as well as a field for the doctor making the referral. The templates also automatically include three patient identifier fields and a field for relevant history, in addition to the other requirements outlined in criterion 1.6.2. The service’s electronic referrals are encrypted. Any handwritten referrals are copied into paper patient health records or scanned into electronic patient health records.

Staff members record the date, time and content of any telephone referrals they make for patients. Any appointments made for patients in relation to a referral are also documented in their health record.

The remote clinic has standardised forms for use with the Royal Flying Doctor Service.

Showing how you meet Criterion 1.6.2

Below are some of the ways in which an Aboriginal community controlled health service might choose to demonstrate how it meets the requirements of this criterion for accreditation against the Standards. Please use the following as examples only, because your service may choose other, better-suited, forms of evidence to show how it meets the criterion.

  • Maintain a policy on referral documents that includes using at least three patient identifiers.
  • Audit patient health records, demonstrating that appropriate referral letters are prepared, patient informed consent is provided and patient confidentiality is protected.
  • Ensure new patient demographic sheets are filled out and included with the patient referral documents.
  • Maintain a standard referral template that includes the service’s details.
  • Run encryption software.

Related RACGP Standards 
and criteria

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