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    Two-Way Referral Form PDF

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    catherine joy macalos
    This two-way referral form is being used to transfer a patient from the Rural Health Unit of McArthur in Leyte to another hospital. The form collects important patient information like name, age, vital signs, diagnosis, and treatment provided. It also allows the receiving hospital to provide feedback on the patient's status and any actions taken upon receipt in their emergency room. The form facilitates the safe and organized transfer of patient care responsibilities between hospitals.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Two-Way Referral Form PDF

    Uploaded by

    catherine joy macalos
    4K views1 page
    This two-way referral form is being used to transfer a patient from the Rural Health Unit of McArthur in Leyte to another hospital. The form collects important patient information like name, age, vital signs, diagnosis, and treatment provided. It also allows the receiving hospital to provide feedback on the patient's status and any actions taken upon receipt in their emergency room. The form facilitates the safe and organized transfer of patient care responsibilities between hospitals.

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    TWO-WAY REFERRAL FORM.pdf

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    This two-way referral form is being used to transfer a patient from the Rural Health Unit of McArthur in Leyte to another hospital. The form collects important patient information like name, age, vital signs, diagnosis, and treatment provided. It also allows the receiving hospital to provide feedback on the patient's status and any actions taken upon receipt in their emergency room. The form facilitates the safe and organized transfer of patient care responsibilities between hospitals.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    4K views1 page

    Two-Way Referral Form PDF

    Uploaded by

    catherine joy macalos
    This two-way referral form is being used to transfer a patient from the Rural Health Unit of McArthur in Leyte to another hospital. The form collects important patient information like name, age, vital signs, diagnosis, and treatment provided. It also allows the receiving hospital to provide feedback on the patient's status and any actions taken upon receipt in their emergency room. The form facilitates the safe and organized transfer of patient care responsibilities between hospitals.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    )

    TWO-WAY REFERRAL FORM


    MacArthur, Leyte

    Type of Referral: Priority or Emergency Non-Emergency


    Reasons of Referral:
    Referring Hospital: Rural Health Unit of Mc ARTHUR (BHS:

    Referred To: Date/Time:


    Patients Category: Health Insurance (specify) Charity Pay

    Name of Patient:
    Age: Sex: Civil Status: Occupation: Religion:
    Address:
    Responsible Person: Relation: Tel/Cell#:
    Admitting Impression:

    Vital Signs: BP HR/PR RR Temp Wt. Blood Type


    Allergies: Other Vital Data:
    Abstract/History (may attach a separate sheet if necessary)

    Diagnostic Procedure Done/ Treatment Given (pls. specify the date, dose, time last given); (may
    attach a separate sheet if necessary)
    Address:

    Referred by:

    Signature over Printed Name Designation Tel/Cell Number

    RETURN SLIP/ DISCHARGE SLIP (for pick-up by the hospitals designated person)
    MacArthur, Leyte

    DATE
    Referring Hospital/ Clinic: Rural Mc ARTHUR

    To Hospital/ ILHZ/ RHU/ Clinic of Origin:

    From Date Admitted: Date Discharged:


    Name of Patient:
    Age: Sex: Civil Status: Occupation: Religion:
    Address:
    Final Diagnosis:

    Action/s Taken (may attach a separate sheet if necessary)

    Recommendation (may attach a separate sheet if necessary)


    Address:

    Signature over Printed Name of Attending Physician Designation Tel/Cell Number

    ACKNOWLEDGEMENT RECEIPT (for immediate return to hospital/ clinic of origin by


    MacArthur, Leyte

    the accompanying hospital/ clinic personnel)


    DATE/TIME
    Referring Hospital: Rural Mc ARTHUR

    Name of Patient:
    Address: Age: Sex: Civil Status:
    Status/ Condition upon Receipt at ER:
    Action Taken: Admitted Referred to other facility Treated/manage as OPD
    Attachment Received: X-ray results/plates Laboratory results others

    Receiving Hospital Contact Person Tel/Cell Number


    Address:

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