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:

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