Question: Referral to Next Level of Care Provider-Trasmittal Question

We have patient/family discharge instructions that are just given to the patient/family. On this form people document patient's appointment and date. Would this be sufficient to answer yes to the question that asks if there was documentation that the patient was referred to the next level of care provider or does there need to be documentation that this information was sent to the next level of care provider?

Answer:

The question about referral to the next level of care provider is a separate question from whether the continuing care plan was transmitted. In this case, the referral was made and documented in the medical record, so you would select "yes". In addition, a copy of the continuing care plan document(s) must also be transmitted within 5 days of discharge in order to select "yes" to the transmittal question.