Eye Hospital: PATIENT REFERRAL FORM

PATIENT REFERRAL FORM

 

 

 

Referral Date: ____/____/______

Referral addressed to: Dr _______________________

Clinic/ Hospital Name: __________________________

Referrer’s Signature: ___________________________ 

Referrer’s Name: ______________________________

 

Patient - Contact Details:

 

Patient Name: _______________________________________

UHID No: _________________________________________

Mobile number: ______________________________________

Email address: _______________________________________

Address: _____________________________________________

 

  

Reason for Referral: _______________________________________________________________________________________________

_________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Ocular Condition Assessment (Please select one):                          

CATARACT                                             SURGICAL RETINA AND MACULA    

GLAUCOMA                                       CORNEA & ANTERIOR SEGMENT

DIABETES                                          DIABETIC RETINOPATHY                                 

PAEDIATRICS                                        SQUINT                                             

NEURO-OPHTHALMOLOGY

 

Patient – Clinical Details:

        Refraction and BCVA: Date: ____/____/______;\

      

       R:__________________ 6/______;                      L: __________________ 6/______

 

Other Relevant Exam Findings: ___________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

 

Relevant Eye Conditions for Referral of Patient:   Previous Lasik Surgery;   Previous Eye Surgery;   Other (please specify)

 _____________________________________________________________________________________________________

 _____________________________________________________________________________________________________

 _____________________________________________________________________________________________________

 

Relevant Medical Conditions for referral of Patient:   Diabetes;   Other (please specify) 

 _____________________________________________________________________________________________________

 _____________________________________________________________________________________________________

 _____________________________________________________________________________________________________

 

 

Consultant Name:

Consultant Sign:

Eye Hospital : Procedure on destruction of medical records

 

Documented procedures are in place on retaining the patient’s clinical records, data and information

SOP for Retention of Patient Record, Data & Information.
Sr. No.	Process Flow	Responsibility
1	The records are stored for the following retention period for patients records: 1.     IPD Patients records – 5 years 2.     OPD patients Records – 1 year ( Henceforth ) 3.     Medical Legal Records – Life time 4.     Death Records – Life time The non-patient records are retained for the following period of time: 1.     Various registers like auto-clave, fumigation – 2 years. 2.     OT / IPD Register – 5 years	Administration
2	The access to patient record is restricted.	Manager & Medical Director
3	The storing location is protected from dampness, leakages & rodent. Pest control is done once in three months.	Manager & Medical Director
4	During safety rounds this area is particularly seen for appropriateness.	Manager & Medical Director

Various records, data and information are stored under lock and key and not accessible to anyone without due authorization. The room in which it is stored is protected from rodents, dampness, leakage, theft and is under Pest Control Contract.

The destruction of medical records, data and information is in accordance with the laid down procedures

  

SOP for Destruction of Patient Record, Data & Information.
Sr. No.	Process Flow	Responsibility
1	At the end of the retention period, a list of obsolete record is prepared.	Manager & Medical Director
2	A notice is displayed at the reception and newspaper indicating the intention of ...................Hospital to destroy medical records of a particular period.	Manager & Medical Director
3	An appeal in above is made to patients desiring to collect the records within one month.	Manager & Medical Director
4	At the end of the above referred period, the record is destroyed by shredding in front of at least two responsible employees of ...................Hospital and one member from general society.	Manager & Medical Director
5	Record of above is maintained.	Manager & Medical Director

 

 

Eye Hospital : Define process to whom the patient record can be released

 

Documented procedures are in place on retaining the patient’s clinical records, data and information

SOP for Retention of Patient Record, Data & Information.
Sr. No.	Process Flow	Responsibility
1	The records are stored for the following retention period for patients records: 1.     IPD Patients records – 5 years 2.     OPD patients Records – 1 year ( Henceforth ) 3.     Medical Legal Records – Life time 4.     Death Records – Life time The non-patient records are retained for the following period of time: 1.     Various registers like auto-clave, fumigation – 2 years. 2.     OT / IPD Register – 5 years	Administration
2	The access to patient record is restricted.	Manager & Medical Director
3	The storing location is protected from dampness, leakages & rodent. Pest control is done once in three months.	Manager & Medical Director
4	During safety rounds this area is particularly seen for appropriateness.	Manager & Medical Director

Various records, data and information are stored under lock and key and not accessible to anyone without due authorization. The room in which it is stored is protected from rodents, dampness, leakage, theft and is under Pest Control Contract.

The destruction of medical records, data and information is in accordance with the laid down procedures

 

 

 

 

SOP for Destruction of Patient Record, Data & Information.
Sr. No.	Process Flow	Responsibility
1	At the end of the retention period, a list of obsolete record is prepared.	Manager & Medical Director
2	A notice is displayed at the reception and newspaper indicating the intention of .................Hospital to destroy medical records of a particular period.	Manager & Medical Director
3	An appeal in above is made to patients desiring to collect the records within one month.	Manager & Medical Director
4	At the end of the above referred period, the record is destroyed by shredding in front of at least two responsible employees of .................Hospital and one member from general society.	Manager & Medical Director
5	Record of above is maintained.	Manager & Medical Director

 

 

Eye Hospital : Documented procedures exist for retention time of medical records, data and information

 

Documented procedures are in place on retaining the patient’s clinical records, data and information

SOP for Retention of Patient Record, Data & Information.
Sr. No.	Process Flow	Responsibility
1	The records are stored for the following retention period for patients records: 1.     IPD Patients records – 5 years 2.     OPD patients Records – 1 year ( Henceforth ) 3.     Medical Legal Records – Life time 4.     Death Records – Life time The non-patient records are retained for the following period of time: 1.     Various registers like auto-clave, fumigation – 2 years. 2.     OT / IPD Register – 5 years	Administration
2	The access to patient record is restricted.	Manager & Medical Director
3	The storing location is protected from dampness, leakages & rodent. Pest control is done once in three months.	Manager & Medical Director
4	During safety rounds this area is particularly seen for appropriateness.	Manager & Medical Director

Various records, data and information are stored under lock and key and not accessible to anyone without due authorization. The room in which it is stored is protected from rodents, dampness, leakage, theft and is under Pest Control Contract.

The destruction of medical records, data and information is in accordance with the laid down procedures

 

SOP for Destruction of Patient Record, Data & Information.
Sr. No.	Process Flow	Responsibility
1	At the end of the retention period, a list of obsolete record is prepared.	Manager & Medical Director
2	A notice is displayed at the reception and newspaper indicating the intention of ..........Hospital to destroy medical records of a particular period.	Manager & Medical Director
3	An appeal in above is made to patients desiring to collect the records within one month.	Manager & Medical Director
4	At the end of the above referred period, the record is destroyed by shredding in front of at least two responsible employees of ..........Hospital   and one member from general society.	Manager & Medical Director
5	Record of above is maintained.	Manager & Medical Director