Guide
Continuity of care
Continuity of care is whether the next person — you next Tuesday, the MRP on the ward, the family physician after discharge, the specialist you referred to — can see what was done and what is still open. It is not a slogan about 'relationships.' It is handoffs, discharge, and referral loops that actually close. When those fail, patients repeat tests, restart drugs that were stopped, and sit on wait-lists nobody owns.
Three places continuity breaks
Handoff, discharge, and referral. Most clinics are decent at the visit in front of them and weak at the open loop. The chart should show the owner, the timeframe, and how the result gets back. 'Follow up PRN' is not a loop. 'Refer to GI' without a question, a fax confirmation, or a plan if GI declines is not a loop.
| Moment | What the next clinician needs | Common failure |
|---|---|---|
| Shift or service handoff | Unstable problems, pending results, who to call | A story with no tasks, or tasks with no names |
| Discharge | Why they came, what changed, meds in/out, who books what | A summary that lists every normal lab and hides the anticoagulation stop |
| Referral | A question, attachments, urgency, how the answer returns | No tracking; patient told 'we'll send it' and nobody checks |
Handoffs
IPASS and similar structures exist because narrative handoffs drop the sickest problem. If you use a mnemonic, still write the pending items as verbs: 'repeat Hb at 04:00, call if <70, Dr. X covering.' Trauma and ED-to-OR notes should carry times and laterality; see the trauma assessment template. Do not hand off a draft you have not read. An AI-generated summary that invents a pending culture is a new discontinuity.
Handoff block
Identification / location / code status: Why they are here (one line): Unstable / watch-fors: Active problems (numbered): Pending (test — time due — who acts): If/then (call criteria): Who is covering and how to reach them:
Discharge
The family physician needs a usable summary within a timeframe your hospital already promised. Lead with diagnosis, hospital course in brief, meds started/stopped/changed, outstanding results, and the appointments that are booked versus the ones the patient must book. Send it to the EMR the community actually uses, not only to the portal nobody checks. If the patient leaves against advice, say so and what you advised.
- Medication list reconciled, not copied from admission.
- Outstanding imaging or pathology — who calls the patient.
- Work notes and driving advice if relevant.
- Follow-up named (clinic, date if known) rather than 'GP to arrange.'
Closing the referral loop
College complaints about delayed cancer and delayed rheumatology often start with a referral that left the building and vanished. Track outbound referrals: date sent, destination, confirmation of receipt, appointment date if you get one, and a trigger if nothing comes back. The consult question should be one sentence. Attach the last letter, relevant labs, and imaging — not the entire chart unless asked.
Confidentiality still applies
Continuity is not a reason to CC the employer, the school, or a relative. Send to the receiving clinician. See patient confidentiality for circle of care.
Letters and handoffs from the visit you already had
Scribeberry can draft the referral letter, discharge-style summary, or SOAP from the encounter. You still own the loop: send, track, sign. Pro is $99/month after the free trial.
Frequently asked questions
What is continuity of care?
It is the unbroken chain of information and responsibility across visits, settings, and clinicians — handoffs, discharge, and referrals that close.
What should a referral letter include?
A clear question, urgency, relevant history and results, and how you can be reached. Then track that it was received and that an outcome returns.
Who is responsible for outstanding results after discharge?
Name someone. If the discharge summary does not say who will call the pending pathology, assume nobody will.
Can an AI scribe improve continuity?
It can draft a clearer letter or handoff from the visit. It cannot fax the referral, confirm the appointment, or sign for you.
Templates
