When It’s Time to Go: Documenting Referrals

There comes a point in the doctor-patient relationship when the doctor has done all they can, and it is in everyone’s best interest to refer a patient out to another provider.

It might be to co-manage, or fully transfer the patient’s care, to an expert in the presenting condition or to request a medical consultation.  No matter the reason, it is important to maintain a good rapport with the patient and potentially the new provider. Your documentation needs to address the referral process since it is an important part of the patient’s story.

Co-Managing or Transferring Care

When a patient lists a symptom on their intake form or an abnormal finding is discovered during an exam, the doctor is required to take steps to address it. In cases where the issue is not within the chiropractor’s scope to treat or they believe another healthcare provider is better equipped to help the patient, a referral can be made to the appropriate specialist or alternative medicine provider with the intention of co-managing the patient or when appropriate transferring care entirely. Ideally, you should be networking with other doctors on an ongoing basis for moments such as this.

Medical Referral

Under some circumstances, a patient may not be a good candidate for conservative chiropractic care. If in your clinical decision-making process, you determine that the patient has significant contraindications to chiropractic manipulations or does not respond to a trial period of treatment, it may be in the patient’s best interest to stop care and refer the patient for a medical consultation. Once the patient’s condition has been assessed and potentially treated, it may be possible for the patient to return to your office for care.

Proper Referral Documentation

The need to refer a patient to another provider can happen at any time during care. Take care to document the decision-making process that led to the referral as well as the discussion with the patient about the referral, the referral itself, and any follow-up notes. This shows your due diligence in making sure the patient receives the appropriate care. Explain the need for the referral in the Assessment section of the note. Describe what was said to the patient and the steps you plan to take to coordinate the referral with the new healthcare provider.

If the patient is scheduled to return to your office, ask the patient how the visit went and include those comments in the Subjective section of the daily visit note. Review the other provider’s findings and perform an updated evaluation of the patient, document these findings in the Objective section of the note. Be sure to comment on how these results will affect the patient’s care in your office and explain what’s next in the Assessment. In the Plan section, establish your treatment plan to include frequency and duration of care, functional goals and measurements of treatment effectiveness, and recommended services with rationale.

Documentation Should be Sent to the Referred Doctor

It is important to make a great first impression with the doctors you refer to. Not only do you want them to take good care of your patients, but you also hope they will see the value of the services you provide and refer their patients to you. You want to provide enough information to explain the reason for the referral. Send any important notes or exam findings from your records, and any labs or imaging results that are available. This way the patient will not have to repeat tests that have already been done.

The common thread between all doctors is that they must act in the patient’s best interest. When it’s appropriate to refer a patient to another provider, the doctor must properly document the process in the patient’s chart. Not only will this show your commitment to compliance, but it relays to your patients that your priority is their health and wellbeing.

Dr. Colleen Auchenbach graduated with a Doctor of Chiropractic from Cleveland University Kansas City in December of 1998 and enjoyed practicing for over 20 years. Her interest in Medical Compliance began when she earned the 100-hour Insurance Consultant/Peer Review certification from Logan University in 2015. She has been a certified Medical Compliance Specialist-Physician since 2016 and a Certified Professional Medical Auditor since 2022. Dr. Auchenbach joined the excellent team at KMC University as a Specialist in 2020, and as a part of this dedicated team is determined to bring you accurate, current, and reliable information. You may reach her by email through info@kmcuniversity or by calling (855) 832-6562.