Dr. Sam Stethoscope is an Internist who sees patients at the Epic Medical Hospital and writes referrals to providers with different specialties. What records does he need?

• A. User records only
• B. Provider records only
• C. User and provider records
• D. Patient records

Answer: (C)

When coordinating care and writing referrals, you need both sides of the information flow: the patient's records and the receiving provider’s records. The patient (user) records contain the individual's medical history, current medications, allergies, prior diagnoses, test results, and the reason for the visit. This context is essential to assess safety, continuity of care, and what to include in the referral. The provider records hold details about the specialist or clinic being referred to—their contact information, specialty, and any referral-specific notes or requirements. Having access to both ensures the referral is accurate, complete, and directed to the right clinician with the right context for the patient. Relying on only one set leaves important pieces missing: patient data without where it’s going can’t be completed properly, and provider data without the patient history can’t be tailored to the patient’s needs.