Table 1 Variables on the referral form to be completed during the referral
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) |
| Â | Time of departure (if emergency) | Health insurance status | Treatment given |
| Â | Â | Name and address of contact person | Reason for referring to the next level |
| Â | Â | Phone number of contact person | Urgency of referral |