Criterion 1.6.2 Referral documents
Our referral documents to other healthcare providers contain sufficient information to facilitate optimal patient care.
► A. Our health service can demonstrate that referral letters are legible, contain at least three approved patient identifiers, state the purpose of the referral and where appropriate (health records review):
- are on appropriate health service stationery
- include relevant history, examination findings and current management
- include a list of known allergies, adverse drug reactions and current medicines
- are documented in the patient’s health record.
Referral documents are a key tool for integrating the care of patients between one health service and external healthcare providers. Referral documents therefore need to be legible (preferably typed) and contain sufficient current information to allow another healthcare provider to provide continuous and effective care to a patient. Most of the information needed for a referral may be found in the patient’s health summary (see Criterion 1.7.2: Health summaries). Unless the details of a patient’s offence/crime are relevant to the care provided by an external provider or the provider’s safety, then such details should not be included in prisoner referral documents. Patients need to be aware that their patient health information is being disclosed in referral documents and they need to provide consent for this to happen.
In the case of a medical emergency or other unusual circumstances, a telephone referral may be appropriate. This telephone referral needs to be documented in the patient’s health record.
For both medicolegal and clinical reasons, health services need to keep copies of important referral letters in the patient’s health record (eg. new referrals or those for serious conditions). Health services that do not retain any referral letters would have difficulty meeting this criterion.
In referring patients to external providers, it is important for the health service to emphasise the independence of the primary healthcare team within the prison to encourage good communication between external healthcare providers and the health service. Some external providers may be unclear about the relationship between the health service and the prison and be reluctant to provide information about a patient’s healthcare back to the prison health service if there is the belief it will not be treated confidentially. If this is a foreseeable problem for the health service, members of the clinical team may consider explaining to external healthcare providers that patient confidentiality is assured. For example, it may be advisable to have a report specifically addressed to a clinician or case manager within the health service rather than confidential patient health information being addressed to the health service as an entity.
Correctly identifying patients is crucial when referring patients so that it is ensured the right patient receives the right treatment. Approved patient identifiers include:
- date of birth
- patient record number if it exists.
A Medicare number is not an approved patient identifier.
Clinicians should be alert to the common use of aliases by prisoners, to ensure the right patient receives the right treatment.