Performance Measurement Network

Question: Patient Referral to Next Level of Care Provider

For Patient Referral to Next Level of Care Provider, how would you answer the question if there is a referral to the next care provider, but I am unable to find the authorization for release of information in the medical record? It does not appear that the patient refused the aftercare, just did not sign a release of information. Additionally, there is no documentation that the patient refused to sign a release, but at the same time there is no release? If there is no signed release does that equal refusal of aftercare?

Answer:

Even though the authorization to release information cannot found in the medical record, you cannot assume that the patient refused to authorize release of information. If a referral to the next level of care provider is not documented in the medical record, select allowable value 5, the medical record does not contain documentation that the patient was referred to the next level of care provider upon discharge from a hospital-based inpatient psychiatric setting OR unable to determine from medical record documentation.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical, Related Manual - Data Quality Manual
Related documents: HBIPS, Patient Referral to Next Level of Care Provider ,
File:

Copyright © by the contributing authors. All material on this collaboration platform is the property of the contributing authors.
Ideas, requests, problems regarding Performance Measurement Network? Send feedback