Improving Treatment for Drug-Exposed Infants
Treatment Improvement Protocol (TIP) Series 5

Documentation of Referral to Ensure Linkage

These guidelines are predicated on the concept of a continuum of care, based upon drawing from many community-based services. Experience has shown that merely making referrals ensures neither that services are received nor that the service provided is of high quality. Therefore, it is one of the functions of a QA program to monitor linkages to referral sources. A well-designed QA program will routinely monitor a sample of all patient records and all referral sources to ensure linkage. Results of monitoring and actions taken to correct problems and improve service must be documented. Some examples of monitoring are:

• Monitoring patient records to ensure that proper referrals were made.
• Monitoring to ensure that all appropriate and necessary information is shared with the referral agency (such as reason for referral and problems to be addressed).
• Monitoring of referral logs, payment vouchers, or other referral documentation (such as payment appropriate to services provided).
• Monitoring patient records to ensure that there is documentation of linkage (such as documentation that infant was evaluated and accepted for services).
• Monitoring patient records for notes of treatment progress and / or continued service (such as regular documentation of treatment progress).
• Documentation that services are no longer needed (such as documentation of why services are no longer needed and what aftercare services are being provided).