Managing Your Practice
Advisory No. 12

Communication between physicians and other health care providers

• Requesting a consultation
• Reporting to the referring physician
• Telephone discussions between consulting, referring, and co-treating physicians
• Telephone calls to and from nonphysicians
• Referral follow-up
• On-call coverage
• “Curbside” consultations with colleagues
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Failed communication or the failure to document significant communication often contributes to patient injury that leads to litigation. A misunderstanding that leads to injury may anger a patient enough to seek a second opinion – from an attorney. Failure to document significant communication may impede the defense of a medical malpractice lawsuit. To protect your patients and reduce your liability risks, consider the following recommendations and implement those that are applicable to your practice.

Requesting a consultation

To protect patients and the referring physician, consultation requests should be in writing. Most managed care organizations (MCOs) require pre-authorization for consultations, and the authorized consultation requests usually must be submitted in writing on a form provided to the physician by the MCO. Physicians who use these forms should ensure that they are filled out completely in order to provide specialists with important clinical information. For doctors who do not use the managed care forms, MIEC's Consultation Request form can be downloaded from our website at www.miec.com. Click on “New to Practice?” or “Policyholder login,” then “Loss Prevention newsletters,” and “Forms.” The form can be printed on three-part carbonless paper. We recommend that the doctor send the original to the specialist, give a copy to the patient, and file a copy in the patient’s chart. The use of these forms ensures that all involved parties have an accurate account of the referral details.

Reporting to the referring physician 

To ensure continuity and integrity of care, specialists should report promptly the results of an initial evaluation and subsequent contacts with the patient. An easy way for a specialist to keep referring physicians informed is to use the Preliminary Consultation Report Form. The form can be used either for a brief handwritten or typed progress note. It, too, is available at MIEC's website in the Loss Prevention newsletter section.

Telephone discussions between consulting, referring, and co-treating physicians 

Consulting, referring, and co-treating doctors should document in the charts significant telephone discussions regarding patient care. Documentation should include the date, time and specific contents of the discussion. Abbreviated notes such as, “Discussed patient with Dr. X,” are not sufficient. Should either physician be sued for professional negligence, and there is a discrepancy between the physicians' memories, this type of note will not demonstrate what was or was not communicated between the health care providers.

Telephone calls to and from nonphysicians 

When physicians receive telephone calls reporting significant patient-related information from a laboratory, radiology department, an emergency department, patients’ family members, or others, this information should be documented in patients’ charts. Likewise, if a physician calls others to inform them of significant patient details, the caller should document the nature of his or her call and its content. In malpractice litigation, when recollections of telephone conversations differ, documentation is more credible than undocumented memory.

Referral follow-up 

To ensure continuity of care, referring physicians should develop a follow-up system to track patients who have been sent to a specialist. Some referring physicians maintain an index card tickler system to keep track of referrals to specialists. A card with pertinent information (entered on a pre?printed template) is filed for recall 2?3 weeks after the referral is made. On the due date, if no report is received from the consulting doctor, the referring physician’s office can make an inquiry. The same system works in reverse when a consultant accepts a referral. A card is made for each referred patient. Each time a new appointment is made, the patient’s card is advanced in the file box to the appointment date. This serves as a reminder to the consultant that a note to the referring physician is due following the visit, or to tell the referring physician the patient failed to keep the initial appointment. Computerized scheduling programs can also assist physicians to track referrals.

On-call coverage 

Physicians who are on-call for other doctors need an effective method for reporting patient contacts to the primary physician. The On-call Physician’s Form, found on MIEC’s website in the Loss Prevention newsletter section, enables on-call physicians to document details of patient contacts, including phone calls. This form can be printed on two-part carbonless paper, so that the on-call physician can send the original to the covered primary doctor and retain a copy.

Physicians who share on-call coverage are well-served when they have clear agreements about what, how much, and for how long they will prescribe or refill medications for one another; they should also agree on the length of time between when they see one another’s patients and when they inform their off-call colleague about the event.

“Curbside” consultations with colleagues

We know that physicians often discuss medical cases with one another and ask colleagues for opinions and/or recommendations for further treatment of a patient. For example, radiologists often are asked to review a film “on the fly” by other physicians, who do not want a formal consultation. We also know from claims experience that specialists can be held responsible if another clinician renders or omits medical care based upon an informal (and retrospectively, incorrect) “curbside” consultation.

To protect physicians from increased liability, MIEC recommends that when you are approached by a colleague for informal advice, ask the physician to refer the case to you so that you may do a formal evaluation of the patient. However, if you choose to informally review the case with a colleague and provide an opinion/ recommendation, we suggest you routinely, clearly and emphatically introduce your opinion with a disclaimer, saying that your opinion is limited and unofficial, based on incomplete information. Your comments should be general in nature and conclude with a suggestion that the requesting physician refer the patient to you for a formal consultation.

Consider documenting such curbstone consultations using an index card system or something similar. On the card, indicate the date, name of the inquiring physician, and a brief comment about the nature of the informal opinion. The notes should indicate what was not available (e.g., medical records or an examination of the patient) so that the limitations under which the informal consultation was given are documented. The cards can be retained in a chronological file.

Patient safety and professional courtesy are both served by maintaining adequate and timely communications, and documenting them.

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