Should you document if you referred the patient to another specialist?

• A. True
• B. False
• C. Only if the patient pays
• D. Not necessary

Answer: (A)

Yes, you should document if you referred the patient to another specialist. Recording the referral creates a clear transfer of responsibility and communicates the reason for the referral and the plan for follow-up. It also provides a medico-legal record, supports continuity of care, and helps the receiving clinician have the necessary context to continue treatment without gaps or duplicate testing. Payment status does not determine whether documentation is needed, so this should be done in all referrals. Include the date, referring clinician, name of the specialist, reason for referral, any relevant tests or notes, and the agreed follow-up plan.