referral system in community health nursing

1. REFERRAL SYSTEM
PRESENTED BY:
HARPREET KAUR
M.Sc( N) 2ND YEAR NURSING
STATE COLLEGE OF NURSING,DEHRADUN

2. At each level of health care infrastructure, there is
need for support from higher level of infrastructure
and also from secondary & tertiary level hospitals to
strengthen and promote credibility of primary health
care system. It should be emphasized that referral is a
two way process and that the retention of patients in
referral institutions should be as brief as possible.
Referral does not mean transferring responsibility. But,
it’sSharing responsibility in patient care.

3.  Referral system is defined as a system of
transferring cases which are beyond technical
competence of one infrastructure to a higher
infrastructure or institution having technical
competency and all other resources to provide
desired health services.
 Referral is a process of directing some one to
another source of assistance. Referral is the act or
instance of sending or directing some one for
treatment, aid, information or a decision

4. The referral system is vertical in nature.
The cases can be referred from village health post
to SC/PHC, from SC to PHC/CHC and from
PHC to CHC/secondary or tertiary level hospital
and from CHC to secondary or tertiary level
hospital.
Provision is made for bypassing 1 or 2 level
depending upon the nature and seriousness of
cases so that required medical and nursing care
can be given on time to the case and mortality and
morbidity can be prevented and controlled.

5. SUPERSPECIA
LIST
HOSP
TEACHING
HOSPITAL
DISTRICT
HOSPITAL
CHC
PHC
SUB
CENTER
CHW (ANM,
ASHA,VHG etc.)

6. • To provide need based comprehensive care within the
technical competencies & resources at each level of
primary health care infrastructure efficiently and
effectively.
• To help people specialized services available at
higher level institution which are beyond their reach.
• To streamline the appropriate use of PHC infrastructure
and specialized services in order to prevent overloading of
specialized institution by direct uses.

7. •Providing specialist’s services to the patient.
• Propagating the purposes of referral system
among health workers.
• Teaching the nursing personnel for reviewing of
patients, sent for referral.
• Preventing further complications and for
appropriate treatment.
• Sending the patients comfortably to the Referral
institute.

8.  The referral should meet the needs and objectives of the clients
and should be necessary and appropriate- there should be merit in
referral.
 The client should be able to use the referral in an efficient,
effective manner- it should be practical. The referral should be
individualized to the client.
The referral should be timely.
 The referral should be coordinated with other activities.
The referral should incorporate the client and family into
planning and implementation.
 The referral should have the right to refuse the referral.

9.  1. Health System
 Service providers (public and private sector) and quality of care
 Performance expectations
 Involvement of organization
 2. Initiating facility
 The client and their condition
 Protocol of care for that condition at that level of service
 Treat and stabilize client – document treatment provided
 Decision to refer
 3.Referral practicalities
 Outward referral form
 Communication with receiving facility (make arrangements as appropriate)
 Information to the client and their family/support network
 Empathy - understanding of implications for client and family/support
network Referral register to monitor follow-up and gather statistics

10.  4.Receiving Facility
• Anticipate arrival and receive client and referral form
• Provide care – document treatment provided
• Plan rehabilitation or follow-up with client and family/support network
• Back referral form
• Feedback to initiating facility on appropriateness of referral
• Referral register to monitor follow-up and gather statistics
 5.Supervision and capacity building
• Monitor outward and back referrals
• Provide feedback, support and training for health staff
• Provide feedback to central level

11. THE REFERRAL UNITS OF PHC SYSTEM NEED TO:
• Well trained required number of professionals,
medical equipment & supplies, organization
structure etc.
• Continuing training, guidance & supervision of
community health workers.
• Guidance on sanitary measures & to disseminate
information on disease control methods.

12. • Conduct health education sessions.
• Provide logistic supports in terms of
equipment & supplies required at PHC.
• Establish liaison & functional relation with
other sectors involved in social and economic
development.
• Organize transportation facilities for cases to
be referred.

13. • Provide specialized clinical outpatient & inpatient
care continuously.
• Back up primary health care system by providing
PH care messages/teaching.
• Discourage people attending OPD’s directly i.e. to
attend OPD when they have referral card/letter
or a genuine emergency.
• Act as teaching center for health professionals
including community health workers.

14. • When the physician need specified investigation
or advice.
• When the physician is dissatisfied with the
patient's progress or unsure of the diagnosis.
• When the patient or his family shows doubt or
lack confidence in the of diagnosis or
management.
• Medical-legal concerns by the physician, the
patient or both .

15. REFERRAL PROCESS:-
The referral process is a systematic problem solving approach
involving series of actions that help clients use resources for the
purpose of resolving needs. Clients may be individuals or
groups who require assistance from others in order to achieve
their maximum level of functioning.
THE BASIC STEPS FOLLOWED IN THE REFERAL
PROCESS:
Establishing a working relationship with the client.
Define the need for a referral. Set objectives for the referral.
Explore resource availability.
Client decides to use or not use referral.
Make referral to a resource.
Facilitates and follow- up.

16. 1s
t
• From family physician primary health care to
hospital specialist.
2n
d
• From specialist to another
specialist.
3r
d
• From junior specialist to
senior specialist.
4t
h
• from general hospital to
specialized hospital

17. PRIMARY LEVEL ( CHW)
SUBCENTRE(MPHW)
P.H.C RURAL HOSPITAL
SECONDARY LEVEL ( DISTRICT HOSPITAL)
TEACHING
HOSPITAL
TERITARY LEVEL (SPECIALITIES HOSPITAL)

18. 1. Availability of qualified consultants.
2. Physician specialty.
3. Length of training.
4. Unexplained findings.
5. Uncertainty of diagnosis
6. Patient characteristics.
7. Reimbursement plan

19.  For the patient
Prompt diagnosis and management
Save time, money and effort.
Better outcome
 For the family physician
learning and training
Gaining self confidence.
Increase communication between the health care staff
 For the Consultant
 - Improve the quality of the patient's management.
Increase communication between the health care staff

20. Referral System Tools
There are two sample tools on the following pages:
Sample tool 1: Referral form
Prepare one copy to send with the client, and keep one copy in the
client notes.
Sample tool 2: Referral register
The register has a page for referrals made OUT from a facility and
referrals received IN to a facility.
Information on back referral of clients referred out from the facility
should be made on the same line as information regarding the
original referral out. This facilitates follow-up.

21. Name of facility: Referral Form original / copy
Referred by: Name: Position:
Initiating Facility Name and Address: Date of referral:
Telephone arrangements made: YES NO Facilit
y Tel
No.
Fax No.
Referred to Facility Name and Address:
Client Name
Identity Number Age: Sex: M F
Client address
Clinical history
Findings
Treatment given
Reason for referral
Documents accompanying referral
Print name, sign & date Name: Signa
ture:
Date:
Note to receiving facility: On completion of client management please fill in and detach the referral back slip below and send with patient or send by fax or mail.

22. Register of Referrals IN
Date referral
received
Client Name (M or F) Identity No. Referred from
(name of facility / specialty)
Referred for Appropriate
referral
YES / NO
Summary of treatment provided Date Back
referral sent

23. Date referral made Client Name (M or F) Identity No. Referred to
(name of facility / specialty)
Referred for Date Back referral
received
Follow-up
required
YES / NO
Follow-up
completed
YES / NO
Appropriate
referral
YES / NO
Register of Referrals OUT

24. Observe and collect information about the illness,
trauma, related situation, factors etc.
Identifies the nature of illness/emergency and its
seriousness.
Provides immediate treatment care within her
competence, standing orders and resources
available.

25. Assures the casualty/family members/ any other
person accompanying.
Explains about the seriousness of the problem
situation and need for reference to the casualty.
Fills up the referral form as desired and hands over
the same with related documents to be given to
health professionals in referred health center.
Arranges for transport of the patient according to
feasibility as soon as possible.
May do the telephonic consultation or provide
information to referred health center.

26. May accompany the casualty/patient if
required and feasible.
Maintains the records and reports.
Provides follow up care as per treatment and
instructions prescribed by the referral unit.

27. THANKYOU