Policies & Procedures Document Title:

Consultation and Referral

Originating Entity :
Access to Care and Continuity of Care Committee
Date Originated: : 27/10/2009 Document No.: POL-ACC-003A
Approved By: Chairman of Access to Care and Date Revised: 51/ 5 /2010
Continuity of Care Committee
Date of Approval: 27 /01 /2009 Rev. No.: 00

Approved By: Chairman of Steering Committee. Next Revision Date : 51/ 5 /2012
Date of Approval: 51/ 5 /2010 Page 1 of 4

CONTENTS: This policy and procedure deals about the guidelines when doing consultations and
referrals from and in to the hospital.
CRITERIA
1.0. CRITERIA FOR REFERRAL:
1.1. More advanced care is available at another hospital
1.2. Patient or family wants a second opinion
1.3. Patient's health condition or problem is not improving
1.4. Originating hospital does not have medical equipment or staff expertise to meet
patient’s medical needs
1.5. Patient wants to return to original surgeons or physicians who are familiar with
medical problem from a previous hospitalization
1.6. A medical case needing transfer to another hospital
1.7. Internal Transfers – from higher LOC to lower LOC and lower to higher;
1.8. External Transfers requiring a higher level of care
1.9. Emergent - these patients are automatically accepted on request
1.10. External transfers at patient request
1.11. Emergencies such as external transfers requiring a higher level of care.
1.12. Stable - timing of transfer is negotiated as long as the patient is stable.
1. Purpose:
1. To provide an initial physical assessment, investigations and intervention by the doctor.
2. To provide an immediate care until definite treatment will be formulated.
3. To coordinate with specialist the signs and symptoms presented and the need for
comprehensive investigation and treatment.
2-Policy:
1. Observe hospital infection control policy strictly at all times.
2. Obtain written consent duly signed prior to any operation or special procedure
done.
3. Respect patient’s rights and safety must be ensured always.
4. Open a new file to any patient coming to the hospital for the first time to seek any
medical treatment or intervention.
5. Ensure that no patient should be entertained without pin card except in emergency
cases.

Confidential Information
Not to be Reproduced / Disclosed Without Prior Written Approval
 Policies & Procedures
Originating Entity :
Access to Care and Continuity of Care Committee
Date Originated: : 27/10/2009
Approved By: Chairman of Access to Care and
Continuity of Care Committee
Date of Approval: 27 /01 /2009
Document Title:
Consultation and Referral
Document No.: POL-ACC-003A
Date Revised: 51/ 5 /2010
Rev. No.: 00

Approved By: Chairman of Steering Committee. Next Revision Date : 51/ 5 /2012
Date of Approval: 51/ 5 /2010 Page 2 of 4

6. Ensure that individual pin numbers should be maintained for each patient and
must be used permanently whenever patient is coming to 48 model hospital. For
any health services.
7. No patient should be allowed to stay in emergency room for more than two hours
unless the patient is for admission.
8. Prompt triaging of victims in cases of code yellow. Patients are categorized
according to the severity of the injury sustained using basic guidelines:
 Airway
 Breathing
 Circulation
 Disability in order to prioritize the treatment on emergent, urgent and non-
urgent basis.
9. Proper identify of patient should be maintained at all times.
10. Medico-legal cases like drug abuse, alcoholism, gunshot and stab wound injury
caused by fighting should be reported to the police authority.
11. Proper positioning and handling of patients should be observed at all times to
give comfort and prevent further injury.

3. Scope:
The policy is applicable departments
4. Responsibilities:
Responsibility all medical staff in 48 model hospital .
5. Definitions:
1. Consultation - a procedure being conducted in every department wherein the
patient is assessed and evaluated by the doctor and then appropriate intervention is
rendered.
2. Referral - is a procedure done in every department wherein a patient is examined
and evaluated by the doctor and then referred to another doctor for further
investigation and evaluation thus leading to definite diagnosis and treatment.
6. Procedures:
6.1. Upon arrival to the hospital, patient or relative is instructed to open file from
reception. If new, patient will register from reception and open the file.
6.2. File and pin card together with the consultation receipt is presented to nursing staff.
Confidential Information
Not to be Reproduced / Disclosed Without Prior Written Approval
 Policies & Procedures
Originating Entity :
Access to Care and Continuity of Care Committee
Date Originated: : 27/10/2009
Approved By: Chairman of Access to Care and
Continuity of Care Committee
Date of Approval: 27 /01 /2009
Document Title:
Consultation and Referral
Document No.: POL-ACC-003A
Date Revised: 51/ 5 /2010
Rev. No.: 00

Approved By: Chairman of Steering Committee. Next Revision Date : 51/ 5 /2012
Date of Approval: 51/ 5 /2010 Page 3 of 4

6.3. Staff who receives the patient, accompanies patient to the examination room.
6.4. Provide privacy, keep the patient in a comfortable position.
6.5. Wash hands, take vital signs and record to print-out.
6.6. Inform the doctor regarding the patient.
6.7. Assist the doctor during physical examination and anticipate his needs.
6.8. Hand over the print-out to doctor to be filled up by him.
6.9. Provide the necessary treatment ordered by the doctor.
6.10. If condition improves, maximum of 2 hours patient can go home after re-
examination by the doctor. Enter patient’s data and diagnosis to consultation
logbook.
6.11. For referral, nurse should:
6.11.1. Coordinate to the department where the patient will be referred.
6.11.2. Inquire for the available doctor.
6.11.3. Inform the clinic nurse regarding the referral and patient’s condition.
6.11.4. Instruct patient/relative to open the print-out under the name of the
doctor whom he will be referred.
6.11.5. Instruct the porter to accompany the patient per wheelchair or stretcher
depending on patient’s condition together with file, pin no. and newly
opened print-out.
6.11.6. Endorsed patient, files, pin card to OPD nurse of the concerned clinic.
6.12. Special Considerations:
6.12.1. If patient is having difficulty to move from one area to another or
condition does not permit, the doctor whom the patient was referred to
will be the one to go to clinic where the patient is.
6.12.2. If patient needs an appointment for the concerned specialist, it will be
entered through computer and then given to the patient stating the
date, time and reservation number.
7. Documentation Requirements:
None
8. References:

Joint Commission International Accreditation Standards for Hospitals .

48 Model Hospital Internal Policies .

Confidential Information
Not to be Reproduced / Disclosed Without Prior Written Approval
 Policies & Procedures
Originating Entity :
Access to Care and Continuity of Care Committee
Date Originated: : 27/10/2009
Approved By: Chairman of Access to Care and
Continuity of Care Committee
Date of Approval: 27 /01 /2009
Document Title:
Consultation and Referral
Document No.: POL-ACC-003A
Date Revised: 51/ 5 /2010
Rev. No.: 00

Approved By: Chairman of Steering Committee. Next Revision Date : 51/ 5 /2012
Date of Approval: 51/ 5 /2010 Page 4 of 4

Confidential Information
Not to be Reproduced / Disclosed Without Prior Written Approval