Incoming Referral

This page will detail the process with which an incoming referral will be documented in TRAKnet, including performing and recording a medication reconciliation.

Incoming Referral

An incoming referral is a "Transition of Care." CMS defines a transition of care as

The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.1

Specifically, in the case of an incoming referral the patient is moving into the care of the provider.

Documenting Referrals

As with all medically relevant information, it is important to document any transitions of care as structured data on the patient's chart. To accomplish this, from the patient's chart, click on the Referrals button on the bottom of the screen to open the Referrals window.

The top of the Referrals window contains a drop-down menu where the related office visit must be selected. This is the visit that the referral will be referencing and the document that will print in conjunction with the referral letter in the case of outgoing referrals.

Beneath the Visit dropdown menu are three navigational tabs. These are:

  • Visit Note — The body of the visit that was selected in the aforementioned dropdown menu. This is the document that will print if a referral letter is printed.
  • Referral Note — The referral letter template you would like to print can be selected on this tab. A Select Template dropdown menu is listed at the top of the screen; selecting a template from this dropdown menu will populate a print preview of the template.
  • Referral Management — The referral management tab is where documentation recording each transition of care will be entered.

Adding a Referral

From the referral management tab, selecting the green Add button to open the Patient Referrals Editor window. This window will contain all information regarding this referral and serve as the documentation to keep track of all transitions of care. Additionally, this step is required in Advancing Care Information.

Patient Referrals Editor Window

The Patient Referrals Editor Window contains the following information. Required fields are in bold:

  • Referral Date — The date the referral was sent or received.
  • Follow-up Date — If necessary, the date a follow-up on the referral is required.
  • Provider — The provider at the office who is sending or receiving the referral. This will always be a user in TRAKnet.
  • Referring Provider — The provider the referral was sent to or received from. This field will more often than not be populated with the patient's PCP.
  • Order Type — Outgoing (you are sending the patient to another setting of care) or Incoming (you are the recipient).
  • Referral Summary Provided — True or False. Did you provide a summary of the patient's information to the provider you are referring the patient to? This is primarily for an outgoing referral.
  • Referral Summary Provided Electronically — True or False. Did you send the above summary of care electronically?
  • Medication Reconciliation — True or False. When receiving in the patient, did you perform a medication reconciliation? Used for incoming referrals.
  • New Patient — True or False. Is the patient you received a new patient to your office? Used for incoming referrals. This must be true to count for Advancing Care Information.

The Patient Referrals Editor Window also contains a Comments tab where general comments or notes about this referral can be documented.

Finalizing a Referral Record

After entering all necessary information into the Patient Referrals Editor Window, click Save to save this record.

To modify a record after it has been saved, click on the desired record and click Modify.

To delete a record after it has been saved, click on the desired record and click Remove.

To show deleted records, click "Show Deleted"; to then restore these records, click Modify and Save.

Advancing Care Information

This measure is part of the performance measures for Advancing Care Information. It is described as:

Medication Reconciliation
Measure: The MIPS eligible clinician performs medication reconciliation for at least one transition of care in which the patient is transitioned into the care of the MIPS eligible clinician.
Required for Base Score (50%): No
Percentage of Performance Score (up to 90%): Up to 10%
Eligible for Bonus Score: No

Steps in TRAKnet 3.0

  1. Search for a patient.
  2. Open patient and click on Referrals at the bottom of the screen.
  3. Select the Referral Management tab.
  4. Click Add. The Patient Referral box will open.
  5. Enter the following information: Referral Date, Follow-up Date, Provider, Referring Provider, Order Type = Incoming, Medication Reconciliation = True, New Patient = True.
  6. Click Save.

Training Video

See below for more information on the Medication Reconciliation measure of ACI:

(ARCHIVED) Meaningful Use

Documenting incoming referrals and performing a medication reconciliation is a requirement of Meaningful Use with the 2015 guidelines.

Objective #7

Medication Reconciliation
Stage 2
Measure: The EP performs medication reconciliation for more than 50 percent of transitions of care in which the patient is transitioned into the care of the EP.
Exclusion: Any EP who was not the recipient of any transitions of care during the EHR reporting period.

Stage 1
Alternate Exclusion: Provider may claim an exclusion for the measure of the Stage 2 Medication Reconciliation objective if for an EHR reporting period in 2015 they were scheduled to demonstrate Stage 1 but did not intend to select the Stage 1 Medication Reconciliation menu objective.

Video

Meaningful Use Webinar

The below webinar link begins right at Objective 7.

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