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Transfer of Care

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Professional Standards Regarding Transfer of Care

Preamble

In the complex world of medicine, it is imperative that a single physician be identified at all times as the most responsible physician (MRP) for any patient. All patients at all times have a right to know which physician is most responsible for their care. This document sets out the responsibilities of physicians to ensure that there is at all times a MRP for all patients, who is aware of the responsibilities of being the MRP, and whose identity is known to the patient.

In short, there must always be a MRP for any patient. The MRP must, at all times, be aware of his or her status as MRP. The patient must be aware of the identity of his or her MRP.

For the purposes of this document, the definition of the most responsible physician is as follows:

“The term most responsible physician (MRP) generally refers to the physician who has overall responsibility for directing and coordinating the care and management of an individual patient at a specific point in time.” (Source: The Canadian Medical Protective Association, 2012)

Although beyond the regulatory scope of this College, it is recognized that in some situations, the clinician occupying the role of MRP may be a nurse practitioner or other health care provider.

A transfer of care occurs whenever there is a change in the most responsible physician for a particular patient. This can take place with movement of patients between health care locations, providers or different levels of care within the same location as their conditions and care needs change.

Physicians have the primary responsibility to ensure effective transfers of care. Physicians are encouraged to be involved in the design of transitions within the health care system to ensure co-ordination and continuity of care for the benefit of their patients.

This document applies whenever there is a change in the MRP of the patient.  Change in the MRP may occur in the following situations:

  • discharging a patient from a hospital or health care facility with the expectation of follow-up care by another physician outside that facility; and
  • transferring care to another physician within the same or different hospital or health care facility.

 

Professional Standards

  1. When discharging a patient, the MRP must ensure:
    1. there is  a legible summary of active medical problems and treatment plans for the accepting physician; and
    2. the accepting physician, who will be the MRP on discharge, is identified to the patient, and is clearly identified in the patient’s medical record.
  2. When transferring a patient, the MRP must ensure:
    1. the accepting physician has the necessary clinical information to assume care, including a summary of active medical problems and the treatment plan for the patient at the time of transfer; and
    2. the accepting physician, who will become the MRP upon transfer, is clearly identified in the patient’s medical record and has agreed to accept the transfer of care.
  3. In either situation, when discharging or transferring a patient:
    1. professional judgment is required to determine the extent and timeliness of information provided to the accepting physician, and the balance between verbal and written communications; and
    2. the physician must inform the patient that a transfer of care is to take place and identify who is to become the most responsible physician for that patient.

In examining these issues, the College will rely on the obligations regarding medical record keeping as articulated in its Professional Standard Regarding Medical Records.

 

Resources

The Nova Scotia Health Authority provides a set of resources to support communication and documentation practices critical to providing safe, quality care for patients during transitions.

CMPA Good Practices Guide: Handovers Transferring Care to Others

Practising in a community setting – A hub for patient care (CMPA, 2012)

 

Acknowledgements

In developing this standard, the College adapted existing policies from the Colleges of Physicians and Surgeons of Alberta and the College of Physicians and Surgeons of Manitoba.

 

Document History

First approved by the Council of the College of Physicians and Surgeons of Nova Scotia: May 27, 2016

Approximate date of next review: 2019