This page will detail the process behind documenting an outgoing referral.

Outgoing Referral

An outgoing referral is any situation where a referral is being made from the provider to another setting of care. For example, if as a podiatrist the office refers a patient to a surgery center for a surgery, that would be an outgoing referral. As with incoming referrals, all information regarding the outgoing referral must be properly documented in the electronic health record software as structured data.

Documenting Outgoing 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.

Sending a Patient Referral Electronically

To meet the Promoting Interoperability requirements patient referrals must be sent electronically. Follow the below steps to send patient referrals electronically.

• On the Referral Note tab select the Encounter to include in the referral note from the Encounter drop down.
• On the Referral Note tab select the referral template to use from the referral template drop down.
• Click Actions and select Send Electronically.
• Select the Provider to send the referral letter to and click Send Direct or Send Direct & Close.
  • Note that only providers with a direct email will show in the list of providers to send a referral letter to.
• Once the referral letter has been sent electronically a patient referral will automatically be created in the Referral Management tab.

Patient Referrals Editor Window

The Patient Referrals Editor Window contains the following information:

• 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.

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.

Sending a Summary of Care

When performing an outgoing referral it is important to send a referral document to the provider you are referring to. This will ensure that the provider receives all necessary information and, at a more basic level, is a requirement when completing outgoing referrals as part of the Promoting Interoperability Program.

From the Referrals tab on the patient's chart, you are able to generate several pieces of information, as previously mentioned. When sending an outgoing referral, you will select the encounter for which the referral is being perform. The visit note for that date of service will then print when generating the referral letter.

The referral note tab on the Referrals icon of the patient's chart is where the referral letter template you would like to send will be selected. These are customizable under the Manage Templates portion of the system and can contain any information deemed necessary by the provider. Once all information has been entered, click the Actions drop-down menu, then click Send Electronically. This will open a Direct EMR pop up window.

On this screen you will find the Providers List drop-down. From this list you must select the provider who will be receiving the message from you. Only providers who have a direct email address entered on their records will be available in this list. To manage your list of referring providers while on this screen, click the Manage button next to the drop-down menu.

After selecting your provider, you may type a secure message into the Body of the message. This is a free text field.

Once complete, click Send Direct or Send Direct & Close. This will satisfy the "send summary of care electronically" portion of this measure in Promoting Interoperability Program.

Training Video

See below for video instructions on how to perform Promoting Interoperability Sending Health Information in TRAKnet 3.1:

Promoting Interoperability - Support Electronic Referral Loops by Sending Health Information from NEMO Health on Vimeo