- Vibration sensation 01:19 - Introduction 00:00 The following table describes actions in the NSQHS Standards that are relevant to the documentation of clinical information. Proper referral management also has financial implications under both fee-for-service and value-based reimbursement models. All rights reserved. The primary purpose of clinical documentation is to facilitate safe, high-quality and continuous care. Join the Geeky Medics community:

You should include the patients or carers ideas, concerns and expectations. It is important to consider if there is any additional information that needs to be documented, and ensure that information is tailored to a patients specific care needs.

Document any relevant family illness that may be significant (e.g. Details of dose and frequency should also be noted. Essential pieces of information about the patient include: This section should be completed with the details of the General Practitioner with whom the patient is registered. Patient access and availability issues often account for low rates of closing referral loops, appointment scheduling rates, and provider differences. - Introduction 00:00 Check out our other awesome clinical skills resources including: It is vital this section is completed carefully and with the most up-to-date information, to ensure the receiving department/physician can identify and make contact with the patient without unnecessary delay. Health systems rely heavily on shared EHRs to facilitate the referral process but this can be imperfect. To be the first to know about our latest videos, subscribe to our YouTube channel . We also have a collection of 500+ OSCE cases with mark schemes and answers to relevant questions. For example, The American College of Physicians (ACP) authored a closing the loop paper. A referral letter is an essential means of communication between primary and secondary care, giving the receiving clinician/department a detailed summary of the patients presenting complaint and medical history to ensure a smooth transition of care. Each clinical case scenario allows you to work through history taking, investigations, diagnosis and management. Evidence shows that poor documentation of information can lead to: Documentation of information can mitigate some of these safety and quality risks, by ensuring that essential information about a persons care is available to clinicians, and support effective communication.

Patient access and availability issues often account for low rates of closing referral loops, appointment scheduling rates, and provider differences. How information is transferred, communicated and documented for a transition will depend on the situation and purpose of that transition. Document any allergies a patient has, including the type of reaction and when they first experienced it. Documentation is a way in which the reliability of information is maintained, and shared between different treating clinicians and with the patient, their family or carer. These documents have a specific purpose and aim to facilitate the continuity of care. next of kin, main informal carer, emergency contact), GP identifier (national code which identifies the practice), Name of the receiving consultant and/or specialty clinic/department. Failure to follow-up after hospital discharge, Increased costs related to inadequate or reduced care coordination, Lack of referrals to community service providers, Increased presentation of emergency departments and increased lengths of hospital stay, Sub-optimal management of patients conditions, inadequate assessment of functional state and inadequate detection of preventable complications in intensive care units, Lack of availability of important diagnostic results, Medication errors, including delays and omissions of antibiotics, missed medications and dose errors, and emergency medications being ceased accidently or missed, Patient deterioration requiring medical emergency team calls and patient, Aboriginal and Torres Strait Islander patients, Patients moving along the perioperative pathway. A comprehensive collection of clinical examination OSCE guides that include step-by-step images of key steps, video demonstrations and PDF mark schemes. Solutions like WELL help make the most of limited time and resources through automated text outreach. The needs and the capabilities of those who will use the information are considered, and language does not exclude the people who will be using the information. Join the Geeky Medics community: geriatric depression score), Smoking history for someone with suspected lung cancer, Sun exposure history for someone with suspected skin cancer, Industrial exposure for someone with suspected lung disease, Wells score if considering pulmonary embolism. Documentation is a key requirement of the NSQHS Standards (second edition), and there are multiple actions across the NSQHS Standards that recognise documentation as a critical component of safe patient care. - Dorsalis pedis pulse 01:13 In reality, due to breakdowns in communication and information sharing, patients often get lost in the scheduling process and never complete a referral visit. Acronyms and abbreviations are avoided in both design and completion if there is any potential for ambiguity. anaesthesia problems/inability to tolerate MRI), Current treatment (and previous treatment trials), Mood assessment scale (e.g. If relevant, include calculated assessment scales such as: You should include relevant risk factors that are associated with the development of a medical condition that is being considered in the differential diagnosis: Specific risk assessment scores can also be included such as: If investigations have been requested but the results are not yet available you should document the type of investigations and the date they were requested. Recorded information correctly reflects the event being documented. Copyright 2022 ACSQHC. Clinical coding data is used for health resource planning and allocation, epidemiological studies, clinical benchmarking, and financial reimbursement determined on casemix based payments. The material contained on this site may include the views or recommendations of third parties, and does not necessarily reflect the views of the Commonwealth of Australia, or indicate a commitment to a particular course of action. Care packages (e.g. Note that this may be different from the physician the patient presented to or the doctor who is referring the patient onfor further care. Twitter: http://www.twitter.com/geekymedics This guide gives a detailed description of each section that may be included in a typical referral document. Accurate documentation of diagnoses and patient care interventions ensures correct translation of data and appropriate coding. Poor referral management and failure to close the referral loop are also harmful to the health of patients. Clinical coding is a health administration function that abstracts clinical information from the healthcare record for the assignment of standardised ICD-10-AM (International Statistical Classification of Diseases and Related Health Problems) and ACHI (Australian Classification of Health Intervention) codes. Available at: [, Academy of Royal Medical Colleges (July 2013). The referring practitioner should carefully document the details surrounding each of the patients presenting complaints to clearly convey the salient details to the receiving clinician such that they can gain a clear picture of the clinical situation and are able to make a reasonable and informed judgement on the case. Whether in electronic or paper, forms and checklists must provide enough space for accurate and legible completion and must include clear instructions about how they should be completed. DO NOT perform any examination or procedure on patients based purely upon the content of these videos. The hospital assumed specialists would see new referrals in the EHR, the scheduling department would schedule these referrals in a timely manner, and the referring providers would receive status reports on the outcome of their referrals. Twitter: http://www.twitter.com/geekymedics This video demonstrates how to assess upper limb pulses in an OSCE setting including: - 150+ PDF OSCE Checklists: https://geekymedics.com/pdf-osce-checklists/ suicide, overdose, self-harm, self-neglect), The risk to others (risks to care professionals or third parties), If a best interests decision has been made because a patient lacks capacity this should be documented clearly, Scottish Intercollegiate Guidelines Network (1998). - 2500+ OSCE Flashcards: https://geekymedics.com/osce-flashcards/ A key factor in optimal patient care is referral scheduling and management, the process in which a patient transitions to the next step in care. When a referral is ready for scheduling, it is critical that organizations proactively contact patients with the right message at the right time in order to improve patient outcomes. This is a general overview of writing a referral letter, however, in practice, each letter is tailored based on the clinical context, so not all information mentioned in this guide needs to be included in every letter (as it may not be relevant). Twitter: http://www.twitter.com/geekymedics Subscribe to our newsletter to be the first to know about our latest content: https://geekymedics.com/newsletter/ How to Feel a Pulse | Radial & Brachial Pulses - OSCE Guide. To ensure safe care, complete and accurate health information needs to be available and shared in a timely way to clinicians responsible for care, and to patients, families and carers. You can check out our guide to peripheral vascular examination here: https://geekymedics.com/peripheral-vascular-examination/ You can check out our guide to the upper limb neurological examination here: https://geekymedics.com/lower-limb-neurological-examination/ For example, a Duke University study analyzed the appointment completion rate of primary care referrals to specialists in a large health system. . Facebook: http://www.facebook.com/geekymedics Relevant, up-to-date information is immediately at hand and easy to locate or searchable (physical accessibility). - Medical Finals Question Pack: https://geekymedics.com/medical-student-finals-questions/ - Posterior tibial pulse 01:06 In reality, due to breakdowns in communication and information sharing, patients often get lost in the scheduling process and never complete a referral visit. If you'd like to support us and get something great in return, check out our awesome products: You don't need to tell us which article this feedback relates to, as we automatically capture that information for you. privacy and confidentiality). large print, braille). A collection of surgery revision notes covering key surgical topics. Document if you have given information to other third parties involved in the patients care. The study found that only about 35% of analyzed referral scheduling attempts resulted in documented complete appointments. YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LjhrLUdpajEtQ0JZ, YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LjZFc0hPcnV2MlNN, YouTube Video VVVram5yRUhROGJRUW1sZk5kQVFDXzV3LkNHTlI0YmJuYkRB, Start typing to see results or hit ESC to close, Extended Focused Assessment using Sonography in Trauma (eFAST), Measuring & Recording Urine Output OSCE Guide, Explaining a Diagnosis of Acne Vulgaris OSCE Guide, Explaining a Diagnosis of Psoriasis OSCE Guide, Explaining the Use of an Adrenaline Auto-injector OSCE Guide, Cervical Cancer and Cervical Intraepithelial Neoplasia (CIN), medical MCQ quiz platform at https://geekyquiz.com, How to Write an Operation Note OSCE Guide, Full name, title and the patients preferred name, Patient sex (sex at birth to help determine how the individual will be treated clinically), Gender (how the patient identifies themselves), Other identifiers (country-specific or local identifier), Contact telephone number (include mobile and home if available). When referral management is properly executed in both models, patient leakage is reduced since they are optimizing referrals for cost, care coordination, and patient care quality. Y. Yang, M. L. Du, Y. S. Fu, W. Liu, Q. Xu, X. Chen, Y. J. Hao, Z. Liu & M. J. Gao, CC BY 4.0 https://creativecommons.org/licenses/by/4.0. Delays in referrals can also lead to increased mortality, decreased quality of life, and missed opportunities to slow the progression of a disease or condition. For example, information should not just simply list tasks but provide enough information and justification to explain recommendations and instructions (actions to be taken and why), and details of the impact and outcome for the particular patient and family involved. Documentation of information, which is accurate, current, relevant, available and accessible, supports clinicians to deliver safe, high-quality care by ensuring they have correct information to: Increasingly, the delivery of health care involves multidisciplinary teams.

Regardless of the medium (paper or digital), high-quality documentation should follow the same guiding principles as outlined in Table 1. Instagram: https://instagram.com/geekymedics Documentation needs to be an accurate reflection of clinical events and clinician decision making for classification (coding) purposes as well as a method of communication to facilitate continuity of care. Documents are available to clinicians who need them, when they need them, and in language that is easily understood by the intended readership. Provide a succinct summary of the patients past medical history, highlighting conditions that are particularly relevant: Past medical history plays an important role in subsequent care, so it is important the receiving doctor has an accurate summation of this information. After three months of using WELL Health, UNCH Rheumatology improved their referral conversion rate from a disappointing 30% to consistently averaging a high of 75% every month. It should be made clear how quickly you expect this patient to be seen (urgent/soon/routine). The guide has been kept purposefully generic such that it can be adapted for use by anyone, anywhere and for a variety of purposes. This video demonstrates how to perform a sensory assessment of the lower limbs in an OSCE setting including: Frontline clinical support staff typically play an important role in following up on referral scheduling, but staff members also report, about how UNC achieved its referral goals and download the case study. Available at: [. - Radial pulse 00:06 Each section lists the important pieces of information that should be given to the receiving doctor and attempts to explain the rationale behind each part of the document. You have a responsibility to ensure that the systems and processes in your organisation support high-quality documentation, and the integration of information to support safe, continuous patient care. You should consider what your organisations documentation requirements are at all stages of the patient journey. Response (or lack of response) to treatment, Investigation results (e.g. This includes information about the patients medical and social history, about the progress and health outcomes of each intervention or interaction, and information from families and carers. F: +61 2 9126 3613 Mr C presents with an 8mm basal cell carcinoma on the deltoid region of the left arm and is subsequently referred to dermatology for confirmation and excision. A CDC study found that an estimated 41% of U.S. adults had delayed or avoided medical care due to concerns about COVID-19. Using WELL Healths bidirectional messaging, UNCH was able to text its patients about setting up a referral appointment, and patients could instantly text or call back. In a fee-for-service model, referral tracking helps identify additional revenue streams by referring in-network and boosting the use of health care services. A collection of interactive medical and surgical clinical case scenarios to put your diagnostic and management skills to the test. Clinicians transferring care will need to exercise clinical judgement and synthesise information to ensure information transferred is fit for purpose, accurate, current and takes into account the specific needs of the patient. Geeky Medics accepts no liability for loss of any kind incurred as a result of reliance upon the information provided in this video. Effectively communicate and partner with patients. This may include the patient, families, carers and other clinicians across disciplines (deferred accessibility). If the referral is more urgent than routine, the reasoning for this should be documented. - Popliteal pulse 00:52 Instagram: https://instagram.com/geekymedics Referral management has been a challenging process even prior to the COVID-19 pandemic. Always adhere to your medical school/local hospital guidelines when performing examinations or clinical procedures. If an assessment of mental capacity has been undertaken this should be documented including: If a patient has made advanced decisions about their treatment (e.g. From the date that the referral is ordered, UNCHs goal is for an appointment scheduled within three weeks. Tarsal tunnel image. State if there are concerns about how well the patient/carer currently understands the information provided regarding investigations, diagnosis, prognosis and treatment. That means they need to grow revenues while demonstrating better value to payers and taking on more risk, the survey reported. Relevant vital signs should be documented (e.g. - Light touch sensation 00:09 Additionally, the type of care expected should be explicitly stated, for example, inpatient, outpatient or emergency department care.

All relevant information is captured (consider any minimum information content requirements). There are several important points that should be covered in this section if applicable, including: If a patient has been consented for investigation and/or treatment this should be documented clearly. - Introduction 00:00 Communication preferences (if relevant) preferred contact method (sign language, letter, phone, etc) and preferred written communication format (e.g. All the material published on the Australian Commission on Safety and Quality in Health Cares Communicating for Safety resource portal is for information purposes only. Edinburgh. DO NOT perform any examination or procedure on patients based purely upon the content of these videos. Fibroblast and Sage Growth Partners surveyed, healthcare executives who reported that their organizations are losing revenue due to improper referral management and patient leakage. Read more about how UNC achieved its referral goals and download the case study here.

Referral management has been a challenging process even prior to the COVID-19 pandemic. There are also real risks for patient outcomes. Join the Geeky Medics community: Users should exercise their own independent skill or judgement or seek professional advice before relying on it. DO NOT perform any examination or procedure on patients based purely upon the content of these videos. Useful resources that may help you improve documentation of clinical information in your organisation include: Improving documentation at transitions of care for complex patients-142 pages, A Guide to the Safe Use of Electronic Tools for Clinical Handover- 88 pages, T: +61 2 9126 3600 When there is a breakdown in the communication of information between. Always adhere to your medical school/local hospital guidelines when performing examinations or clinical procedures. A collection of data interpretation guides to help you learn how to interpret various laboratory and radiology investigations. There are also real risks for patient outcomes. Standards, policies and procedures set by relevant federal, state and territory governments, health services and professional bodies are adhered to, including rules relating to both clinician and patient identification. Documents are materially durable (not loose paper that is likely to be lost or on thermal paper that can fade). Facebook: http://www.facebook.com/geekymedics Improve your bottom line by sending all patient communications through one console. Fields to be completed in this section are the GPs: This section should include the following details: It is important that the patient is referred to the correct speciality, and two patients with the same diagnosis may well require referrals to different specialities depending on the details of their respective cases, for example: This section is to be completed if the patient is being referred by a practitioner/agency other than their registered GP, as documented in the section above. This video demonstrates how to assess lower limb pulses in an OSCE setting including: Facebook: http://www.facebook.com/geekymedics investigation, diagnosis, treatment) and what the expected outcome is. G. are a frequent occurrence in large health systems with complex referral management and provider networks. concluded that a great majority of practices lack established processes for closing the referral loop. Fourth year medical student at the University of Glasgow. If an examination has been performed, the relevant findings should be noted. Fibroblast and Sage Growth Partners surveyed healthcare executives who reported that their organizations are losing revenue due to improper referral management and patient leakage. Standards for the clinical structure and content of patient records. - Over 3000 Free MCQs: https://geekyquiz.com/ Subscribe to our newsletter to be the first to know about our latest content: https://geekymedics.com/newsletter/ This makes effective referral management all the more challenging as healthcare leaders work to balance limited resources with, from a reduction in non-COVID-related care. Report on a Recommended Referral Document [online]. For UNCH, referral conversion is the ability to receive a referral order and convert it into a scheduled appointment. The healthcare record can be made up of a number of different clinical documents, and is the place in which all relevant clinical information about a patient is stored. The Commonwealth of Australia does not warrant or represent that the information contained on this site is accurate, current or complete. High-quality documentation of clinical information is therefore essential to ensure that clinicians have available all of the information they need to safely transfer the care of a patient. - Geeky Medics OSCE App: https://geekymedics.com/geeky-medics-app/

Check out our brand new medical MCQ quiz platform at https://geekyquiz.com. WELL Health intelligent communications hub unifies and automates patient communication at enterprise scale. - Over 3000 Free MCQs: https://geekyquiz.com/ This type of outreach proved more effective than sending messages through My UNC Chart or leaving phone voicemails that may not be heard. Good documentation contributes to better patient outcomes by enabling information exchange and continuity of care by all members of the healthcare team. For example, a. analyzed the appointment completion rate of primary care referrals to specialists in a large health system. Effectively communicate across transitions with other healthcare providers and across multidisciplinary teams. Referral management can impact a health systems financial health. You can check out our guide to peripheral vascular examination here: https://geekymedics.com/peripheral-vascular-examination/ Specific consideration for patients who are at higher risk, additional information that needs to be documented, Medical records and data-driven healthcare, National Guidelines for On-screen Presentation of Discharge Summaries, Electronic Discharge Summary Systems Self-Evaluation Toolkit, SHAREing Obstetric Care Clinical handover between VMOs and Midwives, Transfer-to-hospital envelope template for transfers from aged care facility to hospital, Inter-hospital Patient Transfer Form based on the ISOBAR structure, Shared transfer of care templates and tools, Recommendations for terminology abbreviations and symbols used in medicines documentation, Recommendations for terminology, abbreviations and symbols used in medicines documentation, Improving documentation at transitions of care for complex patients, A Guide to the Safe Use of Electronic Tools for Clinical Handover, Healthcare records are available to clinicians at the point of care and workforce supported to maintain accurate and complete healthcare records, Processes are developed to provide clinical information into the My Health Record system, Processes for communicating relevant details of patients infectious status whenever responsibility for care is transferred, Document best possible medication history and medication reconciliation, Process for documenting history of medicine allergy and adverse drug reactions, and documenting adverse drug reaction experienced during an episode of care, Documentation of medication reviews, including actions taken as a result, Generate current medicines list and the reasons for any changes, Support clinicians to develop, document and communicate comprehensive plan for care and treatment, Support patients to document clear advance care plans, Document findings of screening and clinical assessment processes, including relevant alerts, in the healthcare record, Clinicians develop and document individualised plan, Current advance care plans are documented in the healthcare record, Specify what information should be documented about the process to correctly match patients to their intended care, Essential information is documented in the healthcare record, including critical information, alerts, risks, reassessment processes and outcomes and changes to the care plan, Clinicians document decisions relating to blood management, transfusion history and transfusion details in the healthcare record, Document individualised vital sign monitoring plans, Document and communicate observed or reported changes in mental state, Poor documentation is a key safety and quality risk, particularly at transitions of care where there is a higher risk of information being miscommunicated or lost, Documentation of clinical information is an essential component of clinical communication and integral to supporting the delivery of safe, high-quality and continuous patient care, High-quality documentation is person-centred, relevant, accurate, complete, up to date and accessible to all members of the healthcare team, High-quality documentation is the responsibility of all health professionals involved in the provision of care. For more information see NSQHS Standards Guide for Hospitals. if my heart stops I do not want to be resuscitated) this should be documented, with the relevant documentation (usually copies) included as part of the referral (e.g. Documentation is an essential component of effective healthcare communication. new or emerging information is recorded, daily progress notes or care plans are documented, and discharge summaries are completed at the time of discharge). This allows us to get in touch for more details if required. Specific consideration should be given when documenting information for patients with complex and chronic healthcare needs, including: These patients are a high risk group for patient safety and the complexity and fluidity of information generated for these patients means that documenting up to date, accurate and complete information can be challenging. A well-functioning patient referral process can help clinicians provide value-based care by reducing referral processing time and overhead costs, streamlining workflows and improving efficiency.

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