Skip to main content

Table 1 Variables on the referral form to be completed during the referral

From: Audit of documentation accompanying referred maternity cases to a referral hospital in northern Ghana: a mixed-methods study

Identification of referring officer Health facility information Patient identification details Patient’s clinical information
Name of referring officer Date Registration number
(Unique identification number)
Presenting complaint(s)
Position Name and address of referring facility Name and address Examination findings
Signature Name and address of facility referred to Sex Investigation results
Date/Stamp Time referred Date of birth/Age Diagnosis(es)
  Time of departure (if emergency) Health insurance status Treatment given
   Name and address of contact person Reason for referring to the next level
   Phone number of contact person Urgency of referral