Annex 7.

11.Decision-making
Sample documents
flowchart for screen-and-treat strategies 351

Sample Form 11.4: Sample letter informing referring clinic of the outcome
of a patient’s diagnostic evaluation
A11
A7

Annex11.
Annex
To: __________________________________ [name of referring clinic]

7. Sample
Decision-making
Name of patient: ________________________ Patient number: ___________

From: __________________________________ [name of referral site]

documents flowchart for screen-and-treat strategies

Patient was seen in our facility on (date): ____________________

Diagnostic tests of ________________ were performed on (date): ______________

Final diagnosis: ________________________________

Management provided ________________________________

Recommended follow-up: ________________________________

Thank you for your referral. Please contact us should you need further information.

Yours sincerely,

________________ ________________ ________________

Name Signature Date