Referrals:

The system shall have the ability to record referral information, including the reason for the referral, the specialist or institution to which the patient was referred, and any referral notes.

Referrals and Prescriptions:

The system shall facilitate the documentation of referrals and prescriptions, including medication prescriptions, lab referrals, imaging referrals, etc. It should also support electronic prescribing where possible.

Referral Creation:

The system shall allow healthcare providers to create and manage referrals, including details such as the reason for the referral, the specialist or institution to which the patient is being referred, and any relevant clinical notes

Integration with Patient Records:

The system shall link referrals to the patient's medical record, ensuring that the referral is connected in the Health Information Exchange Platform and in the future the referred provider has access to relevant medical history, medications, allergies, lab results and other clinical information.

Status Tracking:

The system has the possibility to track the status of each referral, from creation, through the patient's visit to the specialist, to the receipt of the specialist's report. As the digital transformation for secondary care is a future endeavor this functionality should be included in such a way that status updates are provided through the HIEP.

4. Referral Communication:

The system should support communication between referring and receiving providers through the Health Information Exchange Platform to facilitate coordinated care.

5. Standardized Referral Templates:

The system shall provide customizable referral templates, allowing for standardized and complete referral information, which can improve the efficiency of the referral process and the quality of care received by the patient

6. Audit Trails:

The system shall maintain an audit trail of all referral activities, including the creation, modification, and deletion of referrals, with a timestamp and the user's identification.

7. Security and Compliance:

The system shall ensure that all referral data is stored and transmitted securely, in compliance with all relevant regulations

Decision Support: Referral Sets:

The system shall provide standardized lab referral sets based on best practices for common conditions, which can improve efficiency and consistency in care delivery.

HL7 Version 2 Support

The system shall initially support HL7 version 2 for the transmission of healthcare data. This includes …. referrals.

Content for Discharge Summary / Pt Information:

• SOEP Structure Support: The system shall support the documentation of medical records following the SOEP (Subjective, Objective, Evaluation, and Plan) structure.

• Subjective (S): The system shall provide fields for capturing the patient's reported symptoms, medical history, and any other subjective information. This includes but is not limited to the patient's chief complaint, history of present illness, review of systems, and personal and family history. Also including the possibility to register the ICPC-S code

• Objective (O): The system shall enable the recording of objective data gathered during the clinical encounter, such as vital signs, physical examination findings, and results of diagnostic tests.

• Evaluation (E): The system should provide an area for healthcare providers to document their assessment of the patient's condition based on the subjective and objective information. This should include any diagnoses made. It should also give the possibility to register the ICPC-E code

• Plan/Policy (P): The system must allow for the documentation of the healthcare provider's plan for the patient's care, which may include treatments, prescriptions, follow-up appointments, referrals, patient education, and other therapeutic interventions.

Ability to individually track referrals and their outcomes

Ability to manage custom lists of options by instance (names of external partners for referral, places of origin / living)

As a triage staff I want to track where the patient came from (e.g. referral from) so that I can report severity of symptoms and referral location (e.g. if they came from another clinic or hospital)

Review Referral

The user is able to view patient referral information but limited according the user privileges.

The user is able to view a list of Internal and external referrals in order to follow up care.

Discharge/ check out Patient

"The user is able to discharge a Patient and capture patient specific clinical details related to the discharge from the OPD service/ clinics.

The details include discharge diagnosis, and the discharge date and time etc. If the patient is discharged to seek further services, the referral form should be filled out.”

Email External transfer documet

"The user is able to email a formatted version of the external transfer document to the relevant recipient. The email will include relevant clinical information, dates and time and facility header etc.

The referral/transfer sheet should include:

The reason for referral/transfer;

Significant findings;

Procedures and treatments;

A list of current medications;

The patient’s immediate condition;

Where the patient is being transferred;

The type of transportation and required monitoring during transport.

The system should notify the receiving facility."

View a list of external transfers.

The user is able to view a list of external referrals in order to follow up on their progress.
Once the user has received feedback, they can mark the referral as complete.
The external transfer documents and feedback will appear with all the clinical documents on the Clinical Notes list.

Add counter referral notes external referrals.

The user is able to add counter referral feedback to a clinician that referred the Patient in order to maintain the continuity of care.

Print counter referral notes external referrals.

The user is able to counter referral feedback in order to provide feedback via the Patient.

Send follow-up comments for external referrals.

The user is able to mail follow up feedback to a clinician that referred the Patient in order to maintain the continuity of care.

Support Telemedicine

The user is able to request a clinical review and provide a feedback report of exam result for example to obtain consults or advice from providers from referral hospitals, private or other countries
The system shall be able to receive and display results from telemedicine consults.

Determine type of referral

The system will allow the clinician to conduct Individual clinical assessment prior to transfer. The outcome or a decision should be then discussed with patient or care taker and if possible there should be subjective to a consent note from the patient before transfer.
The system should have an assessment form that should trigger the consent form if the end result confirms the transfer
The system allows to conduct a detailed risk assessment to determine the level of risk of the patient should be performed

Pre-transfer package

The system should provide clinical examination and consultation to Stabilization the patient by providing all the medical care necessary to make sure the patient's condition will not deteriorate and their vital signs are within the healthy range. Here the different
After that the patient is stabilized, then the clinician will determine the proper mode of transfer. There are several different ways that a patient can be transferred. Then the system will provide the drop down check with a list of possible means of patient transpiration that keep the patient safe while being appropriate: Airplane or by ambulance or others.
As soon as the patient is ready on the transfer trolley, the nurse in charge should check the availability of transport, clinician roster and bed occupation at destination health facility and request/book through online portal
If the receiving health facility confirms, then the system should automatically discharge the patient and produced all relevant documentation / tests and notes accompany the patient
The system should immediately push patient records to the central shared repository to available the most recent clinical history to enable continuum of care. Patients medical records/or copy AND summary clinical note will include Patient’s medicine drug sheet and prescription and other Relevant documentation which will assist the receiving hospital/facility in planning and delivering safe, effective care to the patient like imaging reports, results of diagnostic tests/assessments, patient evaluation and reason of transfer
Important note:
Currently, The Ministry of health doesn’t in place the Principles for sharing and accessing local shared electronic patient records for direct patient care.

CHW

CHW Referrals

Patient referral

Allow for referral of patient with cancer suspect to high level of care for further investigation and treatment

Require referral

Allow referring client to another level, the system should provide list of available referral points.

Referral /exit

Allow for patient referral to home-based care and or other health facility based on clinical history

Referral/ Exit: Record Referral Outcomes

Allow to record patient outcomes following treatment including death if happened

Video of the patient referral process at AMPATH

https://www.loom.com/share/3cde04e07e5143dab5428b0779ea8122

Referral Order Form

Referral Order Form: Details

Confirm Double-Check Message

Clear Success Message

Referral Tracking Dashboard

a widget on the clinic dashboard to show a list of referrals that have been made to your clinic:

Order a Referral / Service

Configurable Form with Reason

Table showing Referrals and Status

(simple table; decide on columns)

Status may need to be manually update-able with notes. (e.g. patient returns and shares paper referral note, may be printed or handwritten)

Left Nav area to access Referrals and Programs