Write a referral letter

 A standard referral can be printed out, sent to a provider using secure messaging and sent to a patient using Secure Send. If you write a CDA letter, which is the default for specialists, it will be sent to MyHealth Record as a CDA form.

Write a referral letter

Write a referral letter to a specialist or healthcare service provider.

Considerations:

• Secure Send can be used to make SMS or Email referrals to patients in Zedmed v36.5 and later.
• Secure messaging requires recipients to be set up in the Address Book with a messaging provider (e.g. Argus or HealthLink).
• Referrals support Document versioning in Zedmed v37 and later.

To write a referral letter:

1. Start an encounter with the patient.
   For a detailed explanation, see the Start an Encounter article.
   When the encounter starts, the Current Encounter pane will open and display the clinical modules.
2. Select Referrals from the Current Encounter menu.

   

    This will open the Referral Selection screen.
3. Select the Referral Letter tab.

   Selecting the recipient

4. Select the Search icon to open the Address Book Search screen.

   

5. Add an addressee from the Zedmed (practice Address Book) or HealthShare (Zedmed v36.3.3 or later). 
   You can set your preferred default.
   From the Address Book 
   Contains practice-defined addressees, which can be set up for secure messaging. To learn more, see the Address Book guide.
   a) Enter the specialist's family name into the Name field and select Find.
   You can view all the recipients available by selecting Find and leaving the Name field blank.    
        b) Double-click on the specialist's name to add them as the Addressee.        
   From the Healthshare Directory
   Printed referrals for specialists and allied health providers. For detailed instructions, see our Clinical HealthShare guide.
         a) Type in the Practitioner name, Practice name or Specialty name.
         b) Select one of the results displayed to add it as an Addressee.
6. Use the Copy To field if you want to cc another practitioner.
7. Optional: Use the Letter Subject field to add an internal description to the referral. This text will not be included in the referral.

   Composing the referral letter

8. Check the correct letter template is being used.
   The Document field (under Templates) shows the selected template. Use the search option to select a different template.
9. Select Write Letter.
   Some templates may prompt you to respond to dialogues before opening the referral.
   The referral will open and key details will be filled in.
   Optional: Send as CDA/eReferral: creates the referral using a CDA form that can be uploaded to My Health Record.
10. Type in any required information.
11. If you want to attach results:
    
    
    1. Select View > DataToolbar.
    2. Expand the section called Extra Clinical Data.
    3. Double-click Documents, Images or Incoming Documents. 
       The selection depends on how the results were received by Zedmed.
    4. Select the result you want to attach.
       Note: PDFs are not supported.
    5. Click OK, and the selected item will be attached to the letter.
       
12. If you want to add clinical information:
    
    
    1. Select View > DataToolbar.
    2. Locate the clinical information by expanding the categories.
    3. Select a space on the referral letter.
    4. Double-click the information you want to add.
       If the option you selected has no information, nothing will be added.
13. Additional options.
    Auto Text can be selected from the Tools menu and allows you to add pre-written text to the letter.
    The PDF icon on the top right will export the letter as a PDF.

    Sending the referral letter

14. Sending the referral letter
    You can now print the letter out for the patient or send it to the addressee via secure messaging (Argus, HealthLink, etc.)
    For telehealth or patients who may need an electronic copy, you can also Securely Send the referral to the patient.
    Option 1 - Print the referral
        a) Select File >Save from the top menu.
    b) Select Close.
        c) Check that the printer contains the correct paper.
    d) Select Print Referrals and review the print options.
    e) Select OK.
    The referral will be saved in Summary View > Documents > Referral Letters.
    
    Option2 - Send to addressee using Secure Messaging (Argus, HealthLink, etc.)
    a) Select File > Distribute.
    b) Select Yes when prompted to save the document.
    c) Check that Send electronically to all electronic recipients is selected.
    d) Select OK.
    Use the Outbox Viewer to see your sent secure messaging messages.
    Option3 - Send to a patient using Secure Send
    Secure Send (Zedmed v36.5 or later) uses email or ZedSMS to send a referral to the patient or NOK Account Payer using a link to a secure download page. To learn more, see the Patient FAQ and dedicated Secure Send guide.
    a) Select Secure Send.
    The Secure Send button will open the Send screen for the referral in the Today's Referrals section.
    b) Review the Send dialog.
          •  The title will show the referral's details.
    • Select Recipient Email or Recipient Mobile, depending on the patient's preference.
          Additional recipients can be added using a comma.
     Caution - if an incorrect email or mobile number is used, the unintended recipient will be able to access the documents.
    c) Optional: Copy To Mobile or Copy To Email fields using the Clinical Addressbook.
    To remove a CC: use right-click > Remove. The HealthShare directory is only available for email delivery.
         Note: This is different to the referrals Copy To field that is used if you want to notify a practitioner of the requested test.
    d) Optional: Pin not required (v37 and later)
         Overrides the one-time security code requirement - the code sent to the patient to open the portal and access the sent files.
    e) Select Send.
          A message will display that includes the text 'Delivery successful'.
          The patient will receive a link to download the referral, which will be useable for 7 days.
    To view the patient's steps, see the  Secure Send guide.
    'Template not found' will appear if the referral addressee does not have the Zedmed pathology or radiology template.

Write a CDA (specialist) letter

Write and deliver an eReferral using the CDA (Clinical Document Architecture) format. CDA is selected by default for specialists and allows the referral to the uploaded to My Health Record (MHR).

Considerations:

• Quick Documents can also be used to write letters back to referrers. 
• To upload to MHR, the letter must meet the MHR requirements.
• CDA can be deselected by default in Clinical's Tools > My Options > My Health Record > Referrals.

To write a letter or referral using a CDA form:

1. Start an encounter with the patient.
   For a detailed explanation of how to do this, see the Start an encounter article.
2. Select Referrals from the Current Encounter menu.

   

   This will open the Referrals screen.
3. Select the Specialist Letter / Referral Letter tab.
4. In the Addressee field, add the referrer the letter is for.
   Enter the name in the field provided, then select the search icon and double-click the addressee's name from the list. You can also select the search icon with a blank field, then select Find and Yes to view all addressees.
5. Use the Copy to field if you want to cc another practitioner.
6. Use Letter Subject to add an internal description to the referral. This will not be included in the letter itself.
7. Check that Send as CDA/e-Letter is selected.
8. Select Write Letter.
   

   

   The form will open with the title Specialist Letter (for specialists) and eReferral (for doctors). 
9. Enter the information, including the Response Details (for specialists) or Referral Reason (for doctors)
   

   

   Save Draft will save the letter in Summary Views > Referrals with a D (draft) icon.
   Right-click > Edit the letter to resume.
10. Select Next (preview).
    The Specialist letter/eReferral will open. The example below shows an eReferral.
11. Review the letter's content.
12. Select Confirm Content and Send.
    • Confirm Content Without Sending saves the eReferral to Summary Views > Referrals with an A (Approved draft) icon.
    •   Right-click > Send to My Health Record will reopen the eReferral at the Confirm Content and Send step.
13. Select OK on the Referrals screen to close and exit.
    

    

    If the requirements listed at the start of this guide are met, the letter will be:
    
    
    • Uploaded to the patient's My Health Record.
      You can check the upload in the My Health Record Document UI.
    • Sent to the addressee via a secure messaging service.
      You can check the Addressee received the eReferral in the Outbox viewer.
14. Print the letter out if required.
    While the encounter is open, the letter can be printed by right-clicking it and selecting Reprint Referral.