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Managing Referral Templates in the EHR

A referral letter acts as a formal request for consultation or additional care for a patient from another healthcare specialist or facility. These notes ensure a smooth transition of care by providing the specialist with the crucial information needed for accurate diagnosis and treatment planning.

By tailoring referral letters to specific specialties and patient needs, you can:

Save time: Reduce repetitive typing by pre-populating common referral information.
Increase accuracy: Ensure consistent and complete referral details.
Improve communication: Provide specialists with clear and relevant patient information.

How to Set Your Default Referral Note Template

Setting a default referral note template boosts practice efficiency by automatically pre-populating the template for each referral letter. This saves time and allows you to focus on the specific details of the referral.

STEPS

1. Login to your EHR.
2. Go to Administration > EMR Setup > Referral Note Setup
3. On the Referral Note Management page, lists of system defaults and user-created referral templates are available.
4. Select a referral note template and click the Default option next to it.

Notes

There are two available system default referral templates to choose from:
1. Standard Referral Note
2. Standard Referral Note with Inserted Note Content
Please note that for Standard Referral Note formats, users can only modify the template body, assign a logo, include or exclude the most recent note, and set a default attachment. The title will remain unchanged, preserving the standard template name.

Editing and Updating Referral Note Templates

Editing and updating referral templates will save you valuable time and enable you to tailor your communication more effectively. This personalized approach ensures the receiving provider is well-informed, allowing them to deliver the best possible quality of care to your patients.

STEPS

1. Login to your EHR.

2. Go to Administration > EMR Setup > Referral Note Setup

3. On the Referral Notes Management page, select a template you wish to update, click Edit button.

4. On the Edit Referral Note Template, users should be able to modify the following fields:

a. Title – assign a comprehensive title.

b. Template– update content that details the reason for the referral, relevant patient information, and any specific requests you may have for the Specialist.

This section will likely include pre-populated data fields from patient’s charts:

Name
Date of birth
Diagnosis (Problem, ICD-10, Code Status)
Plan
Orders
Procedures
Prescriptions

Notes

Please refrain from modifying items highlighted in yellow as well as the “Follow up” section as these info are pulled from the database.
The logos that are available from the dropdown can be managed from your EHR’s Administration > Practice Setup > Edit Practice Info
Only signed notes will automatically carry the provider’s electronic signature in the Referral Letter.

c. Include Practice Logo – select the logo you want to be displayed on the referral letter. Choose “No logo selected” if there is none.

d. Include Most Recent Note – check this option to automatically include the patient’s most recent clinical note.

e. Default Attachments – this section allows you to designate specific documents or files that will be automatically attached to every referral letter generated from this template.

Click Browse files to upload and attach files.
Click icon to remove an attachment.

5. Click Preview to review and finalize.
6. Click Update to save changes. A successful confirmation message should appear.

Create New Referral Note Template Quickly Using Duplicate Command

The duplicate button lets you quickly create new referral templates from existing ones. This feature allows for further customization, enabling tailored communication with other providers based on the specific needs of each referral.

STEPS

Users should be able duplicate both system defaults and user created templates:

1. Login to your EHR.
2. Go to Administration > EMR Setup > Referral Note Setup
3. On the Referral Notes Management page, select a template you wish to duplicate, click the Duplicate button.
4. After creating a duplicate, users can modify and customize the copied referral note template as needed.

Follow the Steps for Editing and Updating Referral Notes Template outlined in this user guide.

Sending Referral Letters From Your EHR

There are a number of ways to reference referral letters within your practice. These methods ensures that all relevant information is readily available to both the referring and receiving providers, further enhancing the continuity of care.

In this user guide, we will reference the sending of letters with the two most common path:

Path 1 : Send Referral Letters for patients with appointments following the 4-step EMR workflow

Path 2 : Send Referral Letters quickly using right+click or hover box options on patient’s name

Path 1: Send Referral Letters following the 4-Step EMR Workflow

Most practices follow the standard 4-step EMR workflow prior to sending a referral letter. By the time the patient checks out, their entire visit, including assessment, diagnosis, and treatment plan, is complete. This ensures that the referral is based on the most up-to-date and comprehensive information.

STEPS

1. Confirm the patient’s schedule from Today’s Appointment List.
2. Upon patient‘s arrival, check-in the patient and update their charges from the Patient’s Account Page.
3. Move the patient to the exam room, click the patient’s name from Today’s Appointment List > Move to Exam Room.

Notes

When a patient is moved to exam room, provider can now send referral letter through the Patient’s Hover Box. The sending of referral letters is outlined in Step 5 of this process.

4. After the encounter, check out the patient:

Click Check Out from Today’s Appointment List of the patient’s hover box.
The Patient Account Page will open for finalizing payments, setting up follow-up appointments, and sending referral letters if needed.

5. Send Referral Letter

Click the Send Referral button.
On the Edit Referral Note Template, the provider that is configured as “Primary” from Patients > Providers Tab will auto populate the provider details fields.
Use the search function from the Referring Provider dropdown to find and select your specialist or the provider you wish to refer to.
Provider details such as Fax (or any of the fields) can be manually entered if necessary.
Select a Referring Note Template from the dropdown menu if needed.

Notes

The Note Template dropdown lists all available templates from Administration > EMR Setup>Referral Note.

Edit the content of the letter as necessary.
When sending through fax, users may include notes on the Fax Comments.
To upload documents, click Add Attachment then attach files in either way:
- Click Browse Files to upload attachments from your local drive.
- Click Select From EMR Documents, then tick the document(s) you want to attach, and hit Submit.
Click the Fax button to send the referral letter. A confirmation message will display upon successful delivery.

For a more detailed guide of the EMR workflow please refer to: 4-Step EMR Workflow.

Path 2: Send Referral Letters using Right+Click Options on Patient’s Name

This guide simplifies sending of electronic referral letters within your EHR.

STEPS

1. Login to your EHR.
2. Select a patient in either way:

For patient with active appointments, go to Today’s Appointment List, select the patient name then right+click, choose Send Referral Letter
Search for a patient, on the results list, select the patient name then right + click, choose Send Referral Letter.

3. On the Edit Referral Note Template, the provider that is configured as “Primary” from Patients > Providers Tab will auto populate the provider details fields.

4. Use the search function from the referring provider dropdown to find and select your specialist or the provider you wish to refer to.

5. Provider details such as Fax (or any of the fields) can be manually entered if necessary.

6. Select a Referring Note Template from the dropdown menu if needed.

7. The content of the letter can be edited as needed.

8. When sending through fax, users may include notes on the Fax Comments.

9. To upload documents and related notes of the patient, click Add Attachment then attach files in either way:

Click Browse Files to upload attachments from your local drive.
Click Select From EMR Documents, then tick the document(s) you want to attach, and hit Submit.

10. Click the Fax button to send the referral letter. A confirmation message will display upon successful delivery.

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