Professional Documents
Culture Documents
Department of Health
Integrated Community Health services Project (ICHSP)
San Lazaro Compound, Rizai Avenue
The
Local Health
Referral System
Manual
This Manual was prepared by the Department of Heaith through the Integrated
Community Health Services Project in cooperation with the Internal Planning Service
(IPS), with support from the Asian Development Bank (ADB), for the use of the Local
Government Units (LGUs).
LocaiJ{eaCtli 'Re(erraCSystem
TABLE OF CONTENTS
FOREWORD iii
ACKNOWLEDGMENTS iv
LIST OF FIGURES v
LIST OF ABBREVIATIONS AND ACRONYMS vi
I. INTRODUCTION 1
ANNEXES 34
GLOSSARY 59
REFERENCES 60
EocafJ{ea(tfi :Re0rra(System
FOREWORD
The health referral system described in this Manual shall enhance the
operation of the Inter-Local Health Zone (ILHZ) System and the Sentrong
Sigla Program of the Department of Health (DOH). The standard criteria and
procedures in this Manual were based on the guidelines of DOH's Bureau of
Health Facilities and Services (BHFS), National Center for Health Facility
Development (NCHFD), and public health programs. It also considered the
World Health Organization (WHO) guidelines on health referral systems and
the experiences of health personnel relative to the efficient and effective
delivery of health services to the population.
t~~;,a,.11
.' Secretary of Health
Locaf:J{ea{tli 'Re(erra{System
ACKNOWLEDGMENTS
List of Figures
DR Delivery Room
ER Emergency Room
FP Family Planning
GO Government Organization
Local':lfeaftfr. 'R2(erraCSystem
MO Medical Officer
MT Medical Technologist
PO People's Organization
PS Provincial Sanitaria
Locai:J{ea{tn 'Re(erra{System
I. INTRODUCTION
Strengthening the health referral system would upgrade the health care
facility's quality of health services, optimize the use of available state of the
art equipment, and enhance its capabilities in local health planning,
decision-making, and monitoring.
Locai:IleaCtfr 'Re(erraCSystem
For the purpose of this Manual, referral shall refer to the set of
activities undertaken by a health care provider or facility in response to
its inability to provide the necessary medical intervention to respond to a
patient's need, whether real or perceived. It is a regular daily activity of
linking a patient to a needed service.
In its wider context, referral shall encompass referrals all the way
from the community to the highest level of care, and back (i.e., two-way
referral); and referrals within a health facility's internal system. It also
involves not only direct patient care but support services as well (e.g.,
knowing where to get a transport facility to move the patient from one
facility to another. .
2. Types of Referrals
A. Internal referrals are those which take place within the health facility
and from one health personnel to another (i.e., doctor to doctor,
resident to specialist, or nurse to MHO). Reasons for referral may
vary and may be any of the following:
• Opinion or suggestion;
• Co-management; and
.• Further management or specialty care.
The referral system shall operate within the framework of the Inter-Local
Health Zone (ILHZ). In the ILHZ concept, a referral system is often called
two-tiered since it involves mainly (1) the barangay health station, rural
health facility, and primary referral hospital (municipal hospital) which
provides primary medical care, and (2) a core referral hospital (district
hospital) which provides secondary care. In situations where a provincial
hospital falls within an ILHZ's coverage area, the provincial hospital will act
as the core referral hospital. A referral within the ILHZ will only be as strong
as the weakest link in the chain of health facilities.
The movement of people through the health system from the first
contact to the first referral hospital will depend on the referral mechanism.
For the referral system to function well, competent personnel should be
assigned at the lower levels, especially the health centers, with
LocalJ{ealtfi 'ReferralSystem
It is important for health centers to refer only those patients for whom
secondary or tertiary care is essential. In general, referral from a health
center to higher levels should occur in the following situations:
The hospital, on the other hand, shall ensure that referrals coming from
health centers receive prompt attention. A referral back to the health center
shall also be done as soon as the reason for referral to the hospital has
been addressed. Such a system shall ensure that a two-way
communication is established. Referral is a two-way process that involves
cooperation, coordination, and information transfer between the health
centers and the hospitals.
Ultimately, the hospital will benefit from its strong involvement and
collaborative cooperation with the health centers, especially in managing
diseases whose causes have bearings on the public health system.
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!I 5 I..
Figure 1 Operational Framework: Comprehensive Two-Way Referral System
I Community
r..-··------·--l
•BHS
4··········..·..···..·· ··-········-··..··-· ··-··-·-·· J
I
i
PRIMARY !
HEALTH CARE
•
( 1s1 LEVEL)
...__ ....... I
.-_.+;------_.• PRIVATE
RHU
PRIMARY
I HOSPITAL
HEALTH CARE .
I
•
(2ND LEVEL)
PRIMARY !
HEALTH CARE I
MUNICIPAJ..j
DISTRICT ..._--_ (3RD .._...._~i
..- .. LEVEL)
HOSPITAL SECONDARY !
HEALTH CARE I
•
PROVINCIAL
HOSPITAL
......., _ -._.._.. __ _._.._ .,I
TERTIARY
HEALTH CARE
•
(4TH LEVEL)
Legend:
1 . ~ DH ~ +
~ - -•.
1
DH
1 I 1
RHU III .~ RHU
1
Pvt. Clinic
.~
-.
'~
Community
Legend:
ILHZ
TH Tertiary Hospital
DH District Hospital
RHU Rural Health Unit
BHS Barangay Health Station
Pvt. Hosp. Private Hospital
Local' Heaith. 'Referra( System
The Provincial Health Officer (PHO) should initiate the idea of setting up
a referral system with technical support from the DOH. Key individuals from
different health facilities should also be involved.
Preparatorv Phase
C. Documentation
I. Introduction
II. Operation of the Health Referral System
The promotion of the health referral system need not be a fancy event.
This can be done in the form of an orientation meeting to inform all those in
the ILHZ of the existence of such a system, and how it works.
There are several factors that affect the flow of a health referral system.
It depends on the geographical location, competencies of health personnel,
availability of supplies, health facility capability, and the customs and
practices of the people.
3. Referral Procedure
B. Once the reason(s) for the referral has been addressed, the
patient shall be referred back with a corresponding return
referral slip containing the following:
• Diagnosis;
• Diagnostic interventions, if any;
• Therapeutic interventions;
• Condition upon discharge;
• Instructions / advices given;
• Activities to be undertaken by the receiving health facility; and
• Discharge summary, if confined in a hospital.
(communl~)
uD
BHS )
uD
c RHUICHO )
uD
MunicipaVCltyl
DlstrlcU
Private Hospital
uD
ProvinclaVPrlvate
HosDital
uD
Regional
Hosnltal
uD
Medical Center
& Specialty
Center
[ocaf:Jieaflli :ReflrratSystem
( Community J
uD
BHSIRHUICHO
Private Clinics
uD
District Hospital!
City Hospitall
Private Hospital
uD
Provincial
Hnsnltal
LocaiJ{eaCtIi 'Referra{ System
o Immunization
BCG
OPT
OPV
_ Measles vaccine
_ Hepatitis B Vaccine
Tetanus Toxoid
Anti-rabies vaccine
Others _
Common illnesses -
including:
Diarrhea
ARI
Measles
_ Dengue
Local:J{ea[tli 'ReferralSystem
Malnutrition
Other endemic diseases of the area
(e.g., Schistosomiasis)
Malaria
o Immunization
BCG
OPT
OPV
_ Measles vaccine
_ Hepatitis B vaccine
Tetanus toxoid
Anti-rabies vaccine
Others _
o School-based services
_ Reproductive health education and information
_ Smoking, alcohol abuse, and drug dependence
Mental and oral health
Others _
o Occupational Health
_ Pre-employment examination
_ Annual Physical Examination
Health education
Local:Hea{tfi 'Referra{System
o Reproductive Health
Education
_STD
_ Family planning methods
_ Violence against women/children (e.g. rape, domestic
violence)
_ Others _(e.g., pap smear, gram stain)
o Minor Surgeries
_ Circumcision
_ Non-life threatening injuries
Others _
This shall also include current hospital initiatives like the hospital as
center of wellness, breastfeeding, etc. At the minimum, district hospitals
should have the capability to respond to life-threatening surgical
emergencies, such as, chest injuries requiring tube insertion, ruptured
appendicitis, etc. The hospital should have the necessary expertise and
facilities to be able to respond to all of these. (Check box if available in your
facility): Hospital Standards and Technical Requirements (Please refer to
DOH AO # 70-A S2002 for the complete listing):
1. Services Capabilities:
o Clinical/Medical Services
Basic Services
_ Surgery
_a. Major _
_b. Minor _
_ Pediatrics
_ Ob-Gyn
Internal Medicine
_ Dental Service
_ Emergency Service
_ Out-patient Service
_ General Anesthesia (secondary level)
_ Clinical core (secondary level)
o Nursing Services
2. Technical ReqUirements:
o Personnel
• Administrative service
a. Chief of Hospital
b. Administrative Officer
c. Accountant
d. Bookkeeper
e. Cashier
f. Statistician
_ g. Admitting Clerk
h. Medical Record Officer
i. Medical Social Worker
Local:Hea{tli neferra{System
_ j. Dietician, Nutritionist
k. Cook
I. Food Service Worker
m. Building Maintenance
n. House Keeper
o. Storekeeper
_ p. Laundry worker
_ q. Utility worker
r. Driver
• Clinical/ medical
_ a. Chief of Clinics
_ b. Medical Specialists in the following fields:
_ Surgery
_ Radiology
_ Anesthesiology
_ Ob-Gyn
Pediatrics
_ENT
_ Pathology
Internal Medicine
• Ancillary
_ a. Radiology Technician
_ b. Medical Technologist
c. Pharmacist III/II
• Nursing
_ a. Nurse IV /111/11/ I
_ b. Nursing Attendant
o Physical Facilities
• Administration
• Clinical Service
Local:Hea{tfi 'Referra{ System
• Nursing
• Dietetic
• Maintenance, Engineering, and Housekeeping
This group, which will extend services, such as, screening and follow-up
of cases and undertake IEC activities, shall be composed of the following
personnel:
C. Hospital Services
1. Provincial Hospital
2. District Hospital
Ancillary services found at the district hospital are similar to those found
in the provincial hospital. The only difference in capability level is the
absence of specialty level medical diagnosis and treatment. Hence, the
hospital can only execute minor surgeries and serve as the first referral or
contact hospital for serious emergencies before these cases are
transferred to the provincial or other tertiary hospitals.
3. Municipal/Medicare Hospital
4. Extension Hospital
11111111111111111111111111
01126
H107.45L8112004
Local:JfeaCtli 'ReferraCSystem
The Municipal Health Officer (MHO) heads the RHU and is assisted by
the Public Health Nurse (PHN). It is the PHN who directly supervises the
Rural Health Midwives (RHMs) in running the BHS. Most RHUs are
provided with an ambulance, either purchased by the municipal
government or donated by an external source. Communication facilities,
which are critical in a health referral system, should be present.
The BHS is the first facility in the public health system. It is manned by
a cadre of volunteer BHWs (Barangay Health Workers) under the
supervision of the RHM. The MHO normally conducts diagnostic
consultations and gives prescriptions and referrals on a regular basis in the
BHS. The BHWs are trained in preventive health care with a strong
emphasis on matemal and childcare, family planning and reproductive
health, nutrition and sanitation, as well as, prevention and care of common
diseases.
There are two types of human resources involved in the health delivery
system: the hospital-based personnel and the public health personnel.
2. Medical Specialists
4. Chief Nurse
5. Nurse III I II
6. . Nurse I
Occupying the first rank in the nursing ladder, the Nurse I is the bedside
nurse who conducts ward rounds; administers medications according to
doctor's orders; prepares patient's records; assists the physician during
patient examination I treatment, provides information to the patient I family
regarding the patient's condition, and supervises other hospital personnel,
particularly, nursing attendants and Institutional Health Workers (IHWs).
8. Pharmacist 111/11
9. Radiologic Technician
A Medical Social Worker provides services that will meet the social
problems influencing the effectiveness of health and medical care. The
MSWO should have a keen understanding of the inter-relationship between
socio-economic and emotional factors affecting health and wholesome
family and community life.
13. Dentist
The PHN supervises and guides all rural health midwives (RHMs) in
the municipality. He / she handles the health records of the community,
including data on morbidity and mortality cases, program accomplishments,
etc. The PHN also prepares monthly and quarterly reports to the MHO.
The RHM manages the BHS and supervises and trains the BHW in the
community. He / she provides midwifery services and execute health care
to women of reproductive age including family planning counseling and
services. He / she conducts patient assessment and diagnosis for referral /
further management; performs health lEG activities, organizes the
community, and facilitates barangay health planning and other community
health services.
The PS monitors and reports environmental factors that may affect the
health condition of the community, such as; quality of water supply,
airborne and vector-borne diseases, industrial pollution, and the use of
pesticides in agriculture and household sanitation. He / she provides
training for local staff and the community on environmental sanitation and
control of diseases.
Local:JfeaCtfi Referrai'System
The HEPO is the point person for the health information, education,
communication activities among public officials and institutions, the private
sector, and the community. He / she acts as a resource person in
community-based promotional activities and in drafting media releases.
= Number of referrals
Number of in patients
Reporting
The ILHZ or its equivalent shall analyze referral data, identify gaps, and
propose recommendation(s) to improve the referral system.
The ILHZ chief shall prepare a consolidated report and submit it to the
PHO.
Locai:Hea{th Referra{System
1. General Policies
C. Supervisors shall orient and train all hospital and field health
personnel in the operations of the comprehensive referral
system, in the context of local area health zone;
2. Institutional Policy/Guidelines
In conformity with the national policies, and with the concurrence of the
local health board, supporting issuances shall be available in the following
areas:
A. Technical policies
• Accidents;
• Gunshot wounds;
• Stab wounds;
• Action on rape case;
• Alcohol verification;
• Drug test policy;
• Medical/ physical exam; and
• Conduct of Autopsy
a. Autopsy examination
b. Post-mortem examination
B. Administrative policies
3. Procedural Guidelines
1. Policies
2. Procedures
5. Support Mechanisms
On the BHS:
On the RHU:
On the hospital:
Adequate staff, facilities and other resources that support the system
should be considered. Referral shall be in the context of ILHZ.
ANNEXES
iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiil 34 ,
Locai:Hea{tfi 'Referrai System
BHS Level
Responsibility Action
Patient (Old) La Presents 10 card from RHM
Patient (New) 1.b Requests for 10 card from RHM
RHM 1.b.1 Fills-up client card and issues 10 card to
patient
RHU Level (From RHM-RHU Level, Patient within RHU catchment area)
Responsibility Action
Patient from BHS 1. Presents BHS referral slip
OPO Nurse 2. Reviews referral slip, enters patients' data
in client registryllogbook and referral
registry
3. Gets vital signs and records findings and
reviews clinical history
4. Refers patient to MHO
MHO 5. Reviews patient's records, examines,
evaluates and treats patient
6. If case is simple, discharges patient.
6.a.1 Fills-out return referral slip to include
medications/ instruction to be undertaken
OPO Nurse 6.a.2 Records additional information in referral
registry
MHO 6.b If patient was referred due to notifiable
disease, MHO conducts epidemiologic
surveillance and notifies hislher team to
undertake an examination/investigation
PHN 6.b.1 Enters patient's data in notifiable diseases
registry and action undertaken
6.b.2 Re-enters additional data when the disease
surveillance has been done
6.b.3 Fills out return referral slip to include
instruction and actions to be undertaken
MHO 6.c. If patient needs further work-up and
confinement, prepares referral slip to
OistricUProvincial Hospital.
6.c.1 Enters pertinent data, actions undertaken
and reason for referral.
PHN 6.c.2 Records patient's data in referral registry.
6.c.3 Advises patient to go to hospital and
arranges transport.
6.c.4 May accompany the patient to hospital
concerned, if needed.
6.c.5 Shall accompany emergency cases.
7. If not necessary, advises patient to proceed
to health facility concerned to give return
referral slip
Patient 8. Returns referral slip to RHM
Local:Jfealtft 'ReferralSystem
Responsibility Action
Medical Specialist / 1. Evaluates and decides to refer patient
Department Head (note: may coordinate with other health
Resident facility for networking)
Physician-in-charge 2. Prepares detailed and complete clinical
summary, accomplishes referral slip
Ward Nurse including reason for referral and gives to
the Ward Nurse
3. Transcribes in nurse's notes and records in
referral registry
4. If necessary, arranges for ambulance
conduction of the patient
5. Advises and explains instructions to patient
/ patient's companion.
6.a If from the ward, facilitates the discharge of
patient (Refer to Procedure of Issuance of
Clearance)
6.b If from the GPD/ER, advises relatives /
companion to go to the billing section for
payment of used medicines and supplies
(Refer to Billing procedures for patients
from GPO)
6.c Informs medical social worker of referral
Medical Social Worker 7. Provides services to the psychosocial
needs of the patient and family that has
risen from the impact of the plan to refer
8. Prepares Social Case Summary and
referral letter
Specialty Hospital/Higher 9. Upon discharge, accomplishes return
Facility Physician referral slip together with the detailed
complete clinical summary including special
instructions
Patient 10. Gives return referral slip / clinical summary
to the referring hospital.
Referring hospital's 11. Advises patient regarding follow-up
physician 12. Sends back referral slip to RHU/BHS
concerned
LocalJ{ea{tfi 'Re(erra{System
ResDonsibilitv Action
MHO/RHP 1. Accomplishes inter-program / project
referral slip
2. Attaches all laboratory results, provisional
diagnosis and actions to be undertaken
3. Gives it to the Public Health Nurse
PHN 4. Files duplicate referral slip/records in intra-
referral registry logbook
5. Notifies/gives referral to program/project
coordinator concerned
Program/Project 6 Reviews intra-referral and does
Coordinator investigation/surveillance and work-up
needed
7. Records results and makes necessary
recommendations or actions to be
undertaken
8. Returns back intra-referral slip
MHO/RHP 9. Reviews then approves
recommendations/actions to be undertaken
Notifies all concerned
11. Records and files return referral slip
12. Carries out orders
13 Follows-up outcome of actions undertaken
14. I Makes alternative action if necessary
Responsibility Action
Resident Physician-in: 1. Accomplishes inter-departmental referral slip
charge 2. Attaches laboratory and other diagnostic results
Senior Resident (l.e., ECG, ultra-sound, x-rays, etc.)
3. Reviews referral slip and gives provisionary
and differential diagnosis and reason for
referral
Medical Specialist 4. Approves referral slip
Ward Nurse 5. Records referral in Patient's Chart (Nurses' notes)
Resident Physician/Senior 6 Sends referral slip to the department's physician
Resident to whom the patient is being referred to
Department to whom the 7. Reviews referral sliplhistory of present illness,
patient is being refereed to examines patient and evaluates together with
(Resident physician or the referring physician
Senior Resident Nurse) 8. Records findings in the Patient's Chart
9. Makes appropriate suggestions /
recommendations
10. Seeks approval of suggestion/recommendation
from medical specialist concerned
11. Returns inter-departmental referral slip to
referring department
Referring department's 12. Notifies his/her Senior ResidentlMedical
physician Specialist of the results
Referring Department's 13. Carries out suggestions/recommendations and
Ward Nurse orders in the patient's chart
13.a If patient needs to be transferred to the referred
department, carries out physician's order
13.b Records in patient's nurses notes
13.c Notifies Senior Nurse
13.d Transfers patient and does necessary
endorsement of nurses' notes
13.e Records patient in list of ward discharges
Receiving department's 13.1 Receives patient, enters in daily census, carries
Ward Nurse out physician's order and notifies resident
physician
Receiving department's Reviews patient's records and notifies hislher
13.g
Resident Physician senior residenVmedical specialist
Resident Physician in- Records in inter-departmental registry logbook
charge 14.
Local' :Hea{tn 'Re{e rrai System
AnnexB
Sheet 1 Monitoring Form for Incoming Referrals
Local':J{ea[tn 'Referra[ System
Date and Name of Patient Age Sex Complete Medical Referred Reason Method ot Status 0
-
MUNICIPALITY
REFERRED
AGE SEX BARANGAY SPECIFIC REASON FOR REFERRAL CLASSIFICATION OF CASE
FROM
5-14y.o.
14-59 y.o. -
50-64 y.o.
Above 64
Local.:Hea[tfi Referral'System
Top Ten Leading Referred Cases (for all facilities) No.of Cases
1. _
2. _
3. _
4. _
5. _
6. _
7. _
8. _
9. --'-_ _
10.
TOTAL NO. OF REFERRED CASES:
REMARKS:
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.
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. •
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~~~~ ~'jj[§)Il@?~
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LEGAL
• •
.. .-
::~. ~
• •
•
OPD OTHERS
CASE
MED PED OB- SURGERY
GYN
0-11 rno
1-4 y.o.
5-14 y.o.
14-59 y.o.
50-64 y.o.
Above 64
Local:HeaCtfi 'REferraC System
Top Ten Leading Referred Cases (for all facilities) No. of Cases
1. _
2. _
3. _
4. _
5. ~ _
6. _
7. _
8. _
9. _
10.
TOTAL NO. OF REFERRED CASES: TOTAL NUMBER OF RETURNED SLIPS _
REMARKS:
Address
ADDRESS: _
WORKING DIAGNOSIS: _
MANAGEMENT GIVEN: _
By: _
Municipal Health Officer
Printed Name and Signature
Date: _
LocaiJ{eaCtli 'ReferraC System
Address
ADDRESS: _
ADDRESS: Sex CS _
REFERRED BY: _
(Attending physician/health worker in-charge)
Printed Name and Signature
RETURN SLIP
ADDRESS: _
FINAL DIAGNOSIS:
Attending Physician
Printed Name and Signature
Name of Hospital
Address
DISCHARGE SUMMARY
Relation to patient: _
DIAGNOSIS:
REMARKS: (include surgical procedure performed I findings, if any, and instructions for follow-
up)
Name of Hospital
Address
Relation to patient: _
CONSENT
(To be translated into the local dialect, if necessary)
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ consent to be
referred to for the reason/s stated above.
Witness: _
Printed Name and Signature
EocaiJ-{ea{tli Referra{ System
TUBERCULOSIS
~---*
If(-) If (+)
Explanation of Terms:
1. BHS refers to RHU or first referral hospital- when a patient presents with
clinical findings of PTB such as on and off low grade fever, cough, hemoptysis.
2.RHU/first referral hospital refers to core hospital or tertiary provincial hospital-
when there are justifications for admission such as presence of pulmonary
complications or extrapulmonary TB.
3. Core hospital or tertiary provincial hospital refers to medical center or regional
hospital - in the presence of complications
Locai:JfeaCtft 'ReferraCSystem
BRONCHIAL ASTHMA
Laboratories:
peak flow meter - 200 liters/min or lower
ABG-usually respiratory alkalosis with hypoxemia
1. Asthma
Suspect
't
2. Airway • 3. B2 Agonist'_-i.~ 4. Definite YES
Obstruc""'ti:-o-n-+ (In clinic) Improvement
(by PEl (within 2 hr)
• NO
5. PRN B2
~
6.
1
B2 Agonist
+Oral steroid (High Dose)
x2weeks
7. Rerf __,_._-,
12. Other
Disease
13. Relief - - - ' - - - - - - - - - - - 14. Asthma
INO YES
+ Consider Process
15. Other Disease
LocaiJfeaftfi Referrai'System
1. 8HS refers to RHU or first referral hospital - when a patient presents with
difficulty of breathing cough, wheezing, chest discomfort or when known asthmatic
is having another episode
2.RHU/first referral hospital refers to core hospital or tertiary provincial hospital -
when symptoms are not relieved after injectable 82 agonist are given.
3. Core hospital or tertiary provincial hospital refers to medical center or regional
hospital- in the presence of complications
Locai:Hea[th 'ReferrafSystem
Annex D
GLOSSARY
References:
Roland and Coulter, " Hospital Referrals", Oxford University Press, 1992
Dr. E. Sandig, PHO, "Health Referral System Manual for the Province of
South Cotabato", South Cotabato, Philippines, 2001