What should be documented when referring a patient to another provider?

When referring a patient to another provider, it is essential to document the reason for the referral and a description of the patient’s condition. This information is crucial for continuity of care, allowing the receiving provider to understand the patient's needs and the context of the referral. Documenting the reason for the referral ensures that the other provider is aware of any specific concerns or symptoms that prompted the referral, which can guide their examination and treatment.

Comprehensive documentation also helps to protect the referring provider legally, as it creates a record of the rationale behind the referral. It assists in communication between providers and ensures that all parties are aligned regarding the patient's care plan. Meanwhile, other options such as referring only the patient's name, a referral card, or just the patient's insurance information, lack the necessary detail to support effective patient care and communication with the other provider.