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Showing posts with label Home. Show all posts

Tuesday, August 16, 2022

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:

Sunday, March 20, 2022

Ethics Committee Quality Indicator

 

QI N

QI Name

Formula

Unit of Measurement

Ethics committee

1

Percentage of Research activities approved by Ethics Committee

Number of research activities approved by ethics committee     X 100
Number of research protocols submitted to ethics committee

Percentage

2

Percentage of patients withdrawing from the study

Number of patients who have withdrawn from all ongoing studies  X 100
Number of patients enrolled in all on-going studies

Percentage

3

Percentage of protocol violations/ deviations reported

Number of protocol violations/ deviations reported                  X 100
Number of protocol violations/deviations that have occurred

Percentage

4

Percentage of serious adverse events (which have occurred in the organisation) reported to the ethics committee within the defined timeframe.

Number of serious adverse events reported within the defined timeframe     X 100
Number of serious adverse events reported within and outside the defined timeframe

Percentage

BME Quality Indicator

 

QI N

QI Name

Formula

Unit of Measurement

BME

1

Critical equipment down time

Sum of down time for all critical equipment in hours in a month

Value

3

Percentage of calls which having total breakdown time 24 hours

numbers of Total breakdown calls are counted in a month           X 100
 number of calls with total breakdown time less then 24 hours

Percentage

4

Percentage of callswhich are not repeated in month

total numbers of breakdown calls are counted in a month   X 100
total number of calls (with similar nature) which are not
 repeated even once in a month

Percentage

Central Store Quality Indicator

 

QI N

QI Name

Formula

Unit of Measurement

Stores

1

Percentage of consumables procured by local purchase

a. Number of drugs/items purchased by local purchase within formulary  X 100
     Number of drugs/ items in hospital formulary list    
                                                                   
b. Number of drugs/items purchased by local purchase outside formulary X 100
     Number of drugs-Items procured in hospital within as well as outside

Percentage

2

Percentage of Consumable rejected before Goods Received Note (GRN) Preparation

Total quality rejected                          X 100
Total quantity received before GRN

Percentage

3

Percentage of stock outs including emergency items

Number of stock outs                                                                                       X 100
Number of drugs listed in hospital formulary and hospital consumables list

Percentage

4

Percentage of variations from the procurement process

Total number of variations from the defined procurement process X 100
Total number of items procured

Percentage

Medical Record Deptt Quality Indicator

 

QI N

QI Name

Formula

Unit of Measurement

MRD

1

Mortality Rate

a. Number of Deaths                          X 100
    Number of discharges and deaths    

b. Proportional maternal mortality rate= Total no. of Maternal deaths  X 100
                                                                  Total no. of deaths         

c. Proportional infant mortality rate= Total No. of infant deaths  X 100
                                                            Total no. of Deaths

Percentage

2

Bed Occupancy rateaverage length of stay

Number of inpatient days in a given month   X 100
Number of available bed days in that month

Percentage

3

average length of stay

Number of inpatient days in a given month          
Number of Discharges and Deaths in that month

Value

4

Percentage of medical records not having discharge summary

Number of medical records not having discharge summary X 100
Number of discharges and deaths

Percentage

5

Percentage of medical records mot having codification as per International Classification of Diseases (ICD)

Number of medical records not having codification as
per International Classification of Diseases(ICD)              X 100
 Number of discharges and deaths

Percentage

6

Percentage of medical records having incomplete and/or improper consent

Number of medical records having incomplete and/or improper consent  X 100
Number of discharges and deaths

Percentage

7

Percentage of missing records

Number of missing record   X 100
Number of records

Percentage

Blood Bank Quality Indicator

 

QI N

QI Name

Formula

Unit of Measurement

Blood Bank

1

Percentage of transfusion reactions recipient.

Number of transfusion reactions  X 100
Number of units transfused

Percentage

2

Percentage of wastage of blood and blood component

a. Number of Blood and Blood Components units
    wasted among those issued                                    X 100
    Number of blood and Blood  Components units
      issued from the blood bank  

b. Number of blood and blood components units
    wasted at blood bank/ blood storage centre              X 100
    Number of blood and blood components units
       stored in the blood bank 

Percentage

3

Percentage of blood component usage

Number of components used                            X 100
Number of Blood and Blood Products used

Percentage

4

Turnaround time for issue of blood and blood components

Sum of time taken                                                         
Total number of Blood and Blood Components issued

Value