A referral is a recommendation for additional evaluation, treatment and/or other services. Referrals may be required for patients/families to receive additional care at other facilities or by specialists. Referrals are typically required for patients/families to receive proper care at additional facilities and/or entities, such as specialists. Referrals may even be required for transfer/transition to other entities for appropriate care.
Sample AAP Referral Policies:
The Importance of Test Tracking
Test tracking is a vital part in assuring quality medical care. If a test is important enough for the pediatrician to order, it is equally important to track the results. Implementing office policies and procedures can prevent lab results from falling through the cracks. Fail-safe strategies are paramount.
Simply asking parents to call if they have not heard from the practice regarding their results leaves the door open to medical errors and subsequent lawsuits. For many patients, no news is good news. They may assume that if the test results were truly important, the doctor’s office would have called. Depending on the test, waiting on the patient no longer is considered good practice from a risk management perspective.
Checking for lab results at the patient’s next appointment is helpful but may not be an effective practice since not all patients return as requested. Furthermore, follow-up appointments may be too late. A better strategy is to have a reliable tracking system in place to prevent the following:
- Not knowing when test results are missing, (either because the patient never had them performed, the lab mishandled the specimen, the lab did not generate the results, or the practice did not obtain and review the results)
- Filing or scanning vital clinical information without a physician’s review, which can lead to delays in diganosis and/or treatment.
Ensure Tests are Done, Results Reviewed
Following are procedures that can be used to verify whether patients obtain the necessary testing as ordered and that results are received, reviewed and properly addressed. They should be an integral part of a practice’s risk management.
- Inform patients about the indications for the test(s) and document this conversation in the medical record.
- Implement a follow-up system to ascertain whether patients have undergone the recommended test(s) and that the results have been returned to the office. The follow-up system should allow tracking by patient name or ID number, test order date, ordering or responsible clinician,and the date the results were received.
- Indicate in the medical record the date the pediatrician reviewed the results.
- Notify patients of test results (especially significant findings) and document how and when this notification occurred.
- Follow up with patients who have not undergone the recommended test(s). This may include telephone and/or electronic communication. All attempts to reach the patient should be noted in the patient’s chart.
- Document whether follow-up testing, referral or treatment took place.
Sample AAP Test Tracking Policies:
- Diagnostic Test Ordering, Tracking, and Notification Policy
- Laboratory and Imaging Tracking Policy
- Tests: Ordering, Tracking and Reporting Policy
American Academy of Pediatrics