Background
Methods
Setting
Study design
Data collection and procedure
Sample size
Analysis
Results
Referral letters formats
Elements | WHO | HL7 | R1 | R2 | R3 | R4 | R5 | R6 | DH2 | PH1 | PH2 | PH3 |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Patient Identification | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ |
Initiating facility | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ |
Referred to facility | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | |
Clinical history | √ | √ | √ | √ | √ | √ | √ | |||||
Findings | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | |
Treatment given | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ |
Reason for referral | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | √ | |
Documents accompanying referral | √ | √ | √ | √ | √ | √ | ||||||
Referral priority | √ | √ | √ | √ | ||||||||
Maternal history | √ | √ | ||||||||||
Labor details | √ | √ | ||||||||||
Back referral/counter referral | ||||||||||||
Initiating facility | √ | √ | √ | √ | √ | √ | √ | |||||
Referred to facility | √ | √ | √ | √ | √ | √ | √ | |||||
Patient Identification | √ | √ | √ | √ | √ | √ | √ | |||||
Patient history | √ | √ | √ | √ | √ | √ | ||||||
Special investigations and findings | √ | √ | √ | √ | √ | √ | ||||||
Diagnosis | √ | √ | √ | √ | √ | √ | ||||||
Treatment / operation | √ | √ | √ | √ | √ | √ | ||||||
Medication prescribed | √ | √ | √ | √ | √ | √ | ||||||
Please continue with: (Meds, Medical prescription, follow-up, care) | √ | √ | √ | √ | √ | √ |
Study sample
SN | Referral letters format / Hospitals | RH1 | RH2 | DH1 | DH2 | DH3 | HC1 | HC2 | HC3 | PH1 | PH2 | PH3 | Total |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | External RL | 8 | 89 | 7 | 67 | 72 | 64 | 307 | |||||
2 | Internal RL | 48 | 21 | 10 | 79 | ||||||||
3 | ANC, Delivery, PNC RL | 1 | 9 | 61 | 66 | 137 | |||||||
4 | Referral/counter RL | 202 | 90 | 160 | 242 | 32 | 114 | 840 | |||||
5 | DH2 RL | 149 | 149 | ||||||||||
6 | PH1 RL | 575 | 575 | ||||||||||
7 | PH2 RL | 217 | 217 | ||||||||||
8 | PH3 RL | 0 | 0 | ||||||||||
Total | 259 | 209 | 177 | 149 | 242 | 160 | 72 | 244 | 575 | 217 | 0 | 2304 |
Completeness level of referral letters
Referral / Counter referral form completeness (Table 3)
Referral / Counter referral (n = 840) | Referral Hospitals | District Hospitals | Health Centers | Average | Total Average | |||
---|---|---|---|---|---|---|---|---|
RH1n = 202 | RH2n = 90 | DH1n = 160 | DH3n = 240 | HC3n = 114 | HC1n = 32 | |||
Patient Identification (%) | 64.8 | 59.0 | 56.5 | 63.5 | 87.7 | 88.5 | 66.2 | |
Clinical Information (%) | 76.9 | 73.6 | 88.4 | 71.0 | 77.9 | 65.6 | 76.7 | |
Referring Healthcare provider details (%) | 100.0 | 100.0 | 100.0 | 100.0 | 100.0 | 100.0 | 100.0 | |
Counter referral (%) | 6.5 | 0.8 | 2.5 | 0.0 | 0.0 | 47.3 | 3.9 | |
Average completeness of referring (%) |
83.3
| |||||||
Average completeness of counter referral (%) |
3.9
| |||||||
Total average completeness (%)
|
46.0
|
External referral letter completeness (Table 4)
External Transfer Form (n = 307) | RH1 n = 8 | RH2 n = 89 | DH1 n = 7 | HC3 n = 64 | HC1 n = 67 | HC2 n = 72 | Average |
---|---|---|---|---|---|---|---|
Patient Identification (%) | 71.4 | 90 | 100 | 99.8 | 98.7 | 86.7 | 92.9 |
Transfer details (%) | 54.9 | 54.7 | 68.3 | 57.3 | 62.3 | 46.8 | 55.3 |
Clinical Information (%) | 67.9 | 43 | 53.1 | 40.8 | 37.5 | 51.8 | 44.3 |
Vital signs (%) | 29.7 | 30.2 | 41.1 | 48.8 | 32.1 | 21.5 | 32.7 |
Referring healthcare provider details (%) | 97.5 | 92.1 | 91.4 | 95.9 | 83.9 | 64.4 | 84.8 |
Referral feedback & Counter referral (%) | 24.2 | 22.8 | 0 | 48.9 | 43.5 | 66.8 | 42.6 |
Average completeness of referring (%) |
62
| ||||||
Average completeness of counter referral (%) |
42.6
| ||||||
Total average completeness (%)
|
58.8
|
ANC, delivery, and PNC external referral form completeness (Table 5)
ANC, Delivery, and PNC external transfer form (N = 137) | Referral Hospitals | Health Centers | Average | ||
---|---|---|---|---|---|
RH1N = 1 | RH2N = 9 | HC3N = 66 | HC1N = 61 | ||
Patient identification (%) | 77.8 | 66.7 | 71.4 | 68.9 |
70.0
|
Clinical information (%) | 64.3 | 39.7 | 46.8 | 45.7 |
45.9
|
Obstetric history (%) | 50.0 | 59.4 | 65.0 | 54.9 |
60.0
|
Maternal vital signs (%) | 85.7 | 57.1 | 52.6 | 55.3 |
54.3
|
Abdominal examination (%) | 100.0 | 86.1 | 78.0 | 79.9 |
79.6
|
Vaginal examination (%) | 0.0 | 33.3 | 16.8 | 15.5 |
17.2
|
Investigation results (%) | 25.0 | 8.3 | 0.9 | 6.6 |
4.1
|
Received treatment at health facility (%) | 14.3 | 3.2 | 0.0 | 1.6 |
1.0
|
Referring care provider (%) | 100.0 | 88.9 | 93.2 | 83.1 |
88.4
|
Referral feedback/Counter referral (%) | 0.0 | 54.9 | 55.4 | 44.7 |
53.9
|
Average completeness of referring (%) |
46.7
| ||||
Average completeness of counter referral (%) |
53.9
| ||||
Total average completeness (%)
|
47.5
|
Internal referral form completeness (Table 6)
Internal Transfer Form (n = 79) | RH1 n = 48 | RH2 n = 21 | DH1 n = 10 | Average |
---|---|---|---|---|
Client Identification (%) | 39.2 | 31.0 | 30.0 | 35.8 |
Transfer Details (%) | 65.6 | 22.2 | 50.0 | 52.1 |
Clinical Information (%) | 60.4 | 42.9 | 65.0 | 56.3 |
Referring Healthcare Provider (%) | 91.7 | 27.6 | 80.0 | 73.2 |
Receiving Healthcare Provider (%) | 0.0 | 59.0 | 0.0 | 15.7 |
Total Average
|
46.6
|
Self-designed referral form completeness (Tables 7, 8 and 9)
DH2 | Average | |
---|---|---|
Patient Identification (%) | 99.8 |
91.8
|
Transfer Details (%) | 87.2 | |
Clinical Information (%) | 81.5 | |
Referring Health care Provider (%) | 98.7 | |
Counter referral (%) | 0 |
0
|
Total average (%)
|
73.4
|
PH1 | Average |
---|---|
Patient Identification (%) | 99.8 |
Clinical Information (%) | 93.6 |
Referring Healthcare Provider (%) | 99.7 |
Total average (%)
|
97.7
|
PH2 | Average | |
---|---|---|
Patient Identification (%) | 88.6 |
94.3
|
Clinical Information (%) | 94.3 | |
Referring Healthcare Provider (%) | 100 | |
Counter reference (%) | 0 |
0
|
Total average (%)
|
70.7
|
Discussion
Formats of referral letters
Referral completeness
Limitations
Recommendations
-
Dissemination of structured referral letters in hospitals.
-
Introduction of incoming and outgoing referral register in each care institution.
-
Elaboration of national referral guidelines which include but are not limited to the use of a referral decision support system, a triage system to facilitate the coordination between the facilities, including detailed steps for pre- and counter referral investigations; a referral rejection process in case the referral letter misses key information; a referral feedback facilitation; methodology for referral letters archiving in the patients’ records.
-
Including the referral system in the education modules for medical and para-medical professions and organizing regular training sessions on the referral system in continuing education programs will improve the completeness.