Failure to document a referral and the reason for the referral is all too often a subject of litigation. Courts often ask, “Who had the responsibility for the evaluation and treatment?”; “Was it the treating physician or the referring physician?” By documenting the referral and the reason for it, you create the evidence that will protect you in a liability situation. For example, patients sometimes do not keep a referral appointment, oftentimes unbeknownst to the treating physician.
Remeber to record the referral, the scheduled appointment, and the review of letters from the referring physician. Particularly in areas of high-risk referrals, document whether an appointment was made and kept. Many cases have been filed in which the plantiff alleges that the physician never made a life-or-death referral. The same holds true for consultations. With regard to test results, put in place a system for flagging and follow-up on abnormal test rests, along with timely notification to the patient.