Professional Standards

Preamble

This professional standard replaces the Preventing Follow-up Failures Professional Standard and the Consultations/Referrals Professional Standard.                    

All physicians have a professional and ethical obligation to ensure continuity of care for their patients, regardless of whether they are providing primary, consultive, specialist or episodic care. Physicians are expected to use their professional judgement to determine how best to do this while acting in good faith to facilitate access to coordinated care.  

This standard sets out expectations for physicians in the following contexts: 

  • Ordering investigations and referrals,
  • Receiving referrals,
  • Team-based care, and
  • Transfer of care.

Continuity of care does not mean physicians need to personally be available at all times to provide continuous access or on-demand care to patients. Doing so would compromise the health of physicians and negatively impact the quality of care provided to patients.  

Rather, physicians are required to facilitate continuity of care by being available and responsive to their patients’ needs, promoting seamless integration of care within accountable multidisciplinary teams and ensuring patients are provided with information on how to access care when their physician is unavailable.  

Definitions

“Most responsible physician”: the physician who has overall responsibility for directing and coordinating the care and management of a patient at a specific point in time.  (médecin traitant responsable)

“Timely manner”: What is timely depends on the circumstances, the urgency of the presenting issue, and any potential risk to the patient if there is a delay in providing follow-up care. (moment opportun)

“Team-based care”: the provision of health programs and services by two or more health care providers who work collaboratively with patients and their circle of care to deliver coordinated, high-quality health service.  (soins en équipe)

“Temporary absence”: vacations and leaves of absence (e.g. parental leave, education leave), as well as unplanned absences due to, for example, illness or family emergencies. This does not include suspension of a physician’s licence. For extended absences from practice, including suspensions, please see the Closing a Practice Professional Standard.  (absence temporaire)

Ordering investigations and referrals

1. A physician who orders a diagnostic test or makes a referral to another health professional must:

  1. Send orders for investigations and requests for referrals in a timely manner,
  2. have a system in place to receive communications regarding test results,
  3. have a system in place to track referrals made, in order to monitor whether the referrals are being received and acknowledged,
  4. make arrangements for responding to clinically significant test results reported by a laboratory or imaging facility for urgent attention after regular working hours, or in their absence (including vacation or leave),
  5. have a system in place to review test results and consultation results in a timely manner,
  6. communicate a clinically significant test result to a patient in a timely manner, 
  7. notify the patient if any follow-up care is necessary and arrange such care, and
  8. document all contacts and attempts to contact the patient, including failed attempts to notify about follow-up care. 

2. A physician, including a physician involved in team-based care, who orders a diagnostic test and directs a copy of the result to another physician, remains responsible for any follow-up care required unless the physician to whom a copy is directed has agreed to accept responsibility for follow-up care.

3. Before referring a patient to a specialist, ensure patients are adequately investigated. If a primary care assessment of the patient would normally include a physical examination or other investigations, the referring physician must ensure these are done before referral.

4. Referrals for consultations must include the following information:

  1. The patient’s name, health number, and date of birth,
  2. Contact information for the patient,
  3. The date of referral,
  4. The purpose of the referral (i.e. medical opinion only, treatment, transfer of care),
  5. The patient’s medical summary (i.e. allergies/intolerances, medications, previous health problems), and 
  6. The level of urgency of the referral.

5. If a physician receives an investigation report in error, they must inform the laboratory or diagnostic facility of the error in a timely manner.

Receiving referrals

1. A physician who receives a referral from another health professional must:

  1. Have a system in place to review and triage incoming referrals, 
  2. Acknowledge the referral in a timely manner and respond urgently, if required by the circumstances,
  3. Inform the referring health professional of the expected date to see the patient,
  4. Indicate to the referring health professional whether they are able to accept the referral and if they are not able to accept the referral, they must communicate their reasons for declining the referral to the referring health professional and, wherever possible, provide alternative suggestions for care or consultation,
  5. If accepting the referral, contact the patient with an appointment date proportionate to the urgency of the request,
  6. Order all additional investigations relating to the referral unless the referring physician agrees to do so.

2. The consultant must prepare and distribute, in a timely manner, a consultation report to the referring health professional and, if different, the patient’s primary care provider, containing the following information: 

  1. The identity of the patient, consultant physician, referring health care provider, and if different, the patient’s primary care provider,
  2. The date of the consultation,
  3. The purpose of the referral,
  4. A summary of the relevant information considered,
  5. A summary of the conclusions reached,
  6. Treatment initiated or recommended,
  7. Recommendations for follow-up by the referring health care provider,
  8. Recommendations for continuity of care by the consultant,
  9. Recommendations for referral to other consultants (if applicable), and
  10. Advice given to the patient.
  11. If urgent, a verbal report containing the above information may be appropriate, although the consultant must follow up with a written consultation report.

3. A primary care provider is not responsible to follow-up on a consultant’s recommendations if they did not refer the patient to the consultant, unless otherwise agreed to.

4. The consultant must notify the patient, and the referring physician, when the consultation is complete and patient care is being transferred back to the referring health professional or to another health professional. 

5. If the original consultation requires follow-up from the consultant, the consultant cannot request that the referring physician send another referral for subsequent appointments for the same condition.

Temporary absences 

1. Physicians who will be unavailable during temporary absences must:

  1. Make all reasonable efforts to enter into an agreement with an appropriate health care provider and/or service to provide ongoing care during periods of unavailability, ensuring handover at the start and conclusion of the coverage, including management of:
    1. Outstanding investigations and investigation results;
    2. Outstanding referrals and consultation reports; and
    3. Any follow-up care required as a result of the above,
  2. Have a plan or coverage in place that allows other health care providers to communicate or request information pertaining to patients under their care during a temporary absence, and
  3. Inform a patient of ongoing care arrangements where they would have a reasonable expectation of being informed.  

Team-based care

Physicians practicing team-based care must respect the standards set out above. In addition, the following also applies to team-based care: 

1. Continuity of care can be achieved through a seamless integrated service, such as team-based care, by enabling the coordination and sharing of information between different providers. 

2. A physician who participates in a team-based care environment must ensure processes are in place that ensure safe care of patients, including:

  1. A process for team-based review of investigation results and consultation reports,
  2. A process for the timely sharing of patient health information with other providers to support quality patient care, and
  3. Clear processes within the team for timely follow-up care.

Transfer of care

Circumstances may arise where the physician transfers full or partial responsibility of the patient’s care. When a physician is transferring full or partial responsibility for a patient’s care to another health care professional they must: 

1. Ensure the provider taking over full or partial responsibility consents to the transfer of care,

2. Communicate clearly with the accepting health professional,

3. Provide a summary that includes the following information:

  1. Pertinent clinical information, including any outstanding diagnostic tests and active consultations,
  2. Treatment plans and recommendations for follow-up care, and
  3. Identification of the roles of other health professionals involved in the patient’s ongoing care. 

4. Ensure that the patient (or their substitute decision-maker) is informed of the physician taking over their care.

Discharging patients from hospital 

When discharging a patient from the hospital, the physician must ensure a discharge summary is prepared which includes the information necessary for the health professional(s) responsible for post-discharge care to understand the hospital admission, care provided and the patient’s post-discharge health care needs. The discharge summary must include a summary of the consultations that occurred during the hospital admission, and which are relevant to ensuring appropriate post-discharge care by the patient’s primary care provider. 

A discharge summary must: 

1. Be done in a timely manner, according to the circumstances, to ensure appropriate continuity of care. If there is a delay in providing the discharge summary, the physician must provide a summary in a timely manner of the hospitalization directly to the health professional responsible for follow-up care. This summary may be either verbal or written and does not eliminate the obligation for the physician to provide a complete written discharge summary, and

2. Where applicable, be directed to the patient’s primary care provider who will be primarily responsible for the post-discharge follow-up care.

Prior to discharging a patient from hospital to home, the physician must ensure that the patient (or their substitute decision-maker) is informed of the following: 

1. Post-treatment risks, hospitalization risks, and potential complications,

2. Signs and symptoms that need monitoring and when action is required,

3. Whom to contact and where to go if complications arise,

4. Instructions for managing post-discharge care, including: 

  1. medications; 
  2. follow-up appointments or outpatient investigations that have been or are being scheduled; and  
  3. follow-up appointments or outpatient investigations that the patient is responsible for arranging and a timeline for doing so.

The type of communication that is required will depend on the circumstances, which include but are not limited to: (1) the nature of the care provided; (2) the characteristics of the patient; (3) the risks; (4) the signs and symptoms that need monitoring; and (5) the complexity of the instructions for managing post-discharge care. In some instances, verbal communication will meet the standard, while in others supporting written documentation will be required.  In all instances, the communication must be comprehensible to the patient or substitute decision-maker, as the case may be. 

ACKNOWLEDGEMENTS 

The College acknowledges the assistance of the College of Physicians and Surgeons of Alberta, the College of Physicians and Surgeons of Ontario, and the College of Physicians and Surgeons of Newfoundland in preparing this document. 

AUTHORITY DOCUMENTS

Medical Act, 1981

APPROVALS

Approved by Council: October 24, 2024
Effective date: January 6, 2025
Version: Original
Last Amended: N/A

REVIEW DATE:

January 2028