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Explanation of Referral Forms

 

General Information

Referral forms were developed to help us keep track of patients seen in the Batey medical clinics, connect the clinic work more directly to the hospital and help patients receive specialized treatment that is unavailable with a Batey clinic. The referral forms should always be given to the patient so they have an explanation, in hand, when they arrive at the hospital. Any patient given a referral form should also have his/her Batey consult card marked with a highlighter by the consultant. This makes it easier for us to record the number of referrals made and also to identify the patients who will be coming to the hospital for further treatment. There are several types of referral forms that will be used, so please choose the appropriate form, as described below. No, we are not turning into managed care, just trying to organize the work a little bit better! Thanks for your help.

 

Surgical Referrals

The surgery referral forms should be used for all types of surgery EXCEPT tubal ligations. This includes eye surgery (cataracts), general surgery (hernias, etc.) and plastic surgery. A list of dates for surgical teams will be provided for the leader of each medical team to use as a reference when patients are asking about surgical dates. Surgeries will be scheduled by Kristy Engel prior to a surgical team but usually not during regular clinic times.

 

Tubal Ligations

Tubal ligation referrals should be noted on the patients card, highlighted and then the patient should be sent to our family planning coordinator. The family planning coordinator will follow-up with the patient regarding birth control options, prior to surgery, and scheduling a date for the surgery. Again, please give the referral form to the patient when completed.

 

Hospital Referrals

Hospital referrals should be used only under the following conditions:

1.      You are confident the patient will make an effort to get to the Good Samaritan hospital for follow-up.

2.     The patient cannot receive adequate treatment at home, even with further education given to family and/or the patient.

3.     The patient requires confirmation of a newly diagnosed disease or special tests to provide appropriate treatment.

Examples of patients who should receive referrals are: newly diagnosed hypertension, AIDS or diabetes, eye disorders requiring an eye exam, broken bones and suspected tuberculosis. Please use your best judgment on any other cases. It is important to remember that whether you are referring a patient for admission to the hospital or solely for further follow-up with a specialist that you are creating a financial burden for the patient that may not be able to be met. You are also removing the patient from his/her support systems. Many times it is better to try and educate the patient and/or family or find a solution that keeps the patient on the Batey. There are obvious cases that cannot be left on the Batey, such as severe dehydration of a baby or post-partum hemorrhaging. If you have any question regarding a referral, please ask Kristy Engel.


Surgery Schedule for 2002

 

January 14-18 Minor general surgery

 

February Plastic surgery (dates not confirmed)

 

February 11-15 Cataract surgery

 

March 4-8 Tubal Ligations (some GYN cases)

 

April 22-26 OB-GYN surgery (not confirmed)

 


Medications Always Needed

Acetaminophen (all ages)

Ibuprofen (all ages)

Vitamins (adult, child, liquid, pre-natal)

Antiacid

Anti-fungal treatments

Vaginal suppositories/creams

Birth control pills

Eye/Ear antibiotics

Cipro

Zithromax

Augmentin

Cough/Cold medicine

Mild Anti-hypertensive


A list of the specialties provided by the Good Samaritan Hospital follows:

Pediatrics

Surgery

Obstetrics/Gynecology

Internal Medicine/Nephrology

Urology

Psychology

Orthopedics

Cardiology

Opthamology

Diabetes

Gastroenterology

Pulmonology/HIV/TB

Family Planning

Dental

Dermatology

General Medicine

 

It is important to specify which specialty you are referring to, although the name of the doctor you are referring to is not necessary. If you are unsure of which specialist to refer to, please ask Kristy Engel. Attached is a copy of the referral form. Additional forms are available from Kristy Engel.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospital General El Buen Samaritano

 

 

 

 

 

 

 

Hospital Referral from Batey Clinic

 

 

 

 

 

 

(Referencia Hospital del Operativo Medico)

 

 

 

 

 

 

 

 

 

 

 

Date (Fecha)______

 

Batey/Barrio_________________

 

 

 

Name of Referring Doctor (please print)__________________________

 

 

 

(Nombre del Doctor de la Referencia)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Name___________________________

 

Age(Edad)_______

 

 

(Nombre del Paciente)

 

 

 

Male(Hombre)/Female(Hembra)<please circle one>

 

 

 

 

 

 

 

 

 

Diagnosis(Diagnostico)__________________________

 

 

 

 

Medical Treatment(Tratamiento Medico) ______________________________________________

 

Reason for Referral__________________________________________________

 

 

(Motivo de la Referencia)

 

 

 

 

 

 

SPECIALITY(ESPECIALIDAD):

Pediatrics(Pediatria) Gen. Medicine(Gral. Medicine) OB/GYN Cardiology(Cardiologia)

(please circle one)

 

Opthamology(Oftalmologia) Diabetes(Diabetis) Internal Medicine(Medicina Interna)

 

 

 

Urology(Urologia) Dental(Dentista) Orthopedics(Ortopedia) Other(Otro)____________

 

 

 

 

 

 

 

 

 

Signature of Referring Doctor_________________________________

 

 

 

 

(Firma del Doctor de la Referencia)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospital General El Buen Samaritano

 

 

 

 

 

 

 

Hospital Referral from Batey Clinic

 

 

 

 

 

 

(Referencia Hospital del Operativo Medico)

 

 

 

 

 

 

 

 

 

 

 

Date (Fecha)______

 

Batey/Barrio_________________

 

 

 

Name of Referring Doctor (please print)__________________________

 

 

 

(Nombre del Doctor de la Referencia)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Name___________________________

 

Age(Edad)_______

 

 

(Nombre del Paciente)

 

 

 

Male(Hombre)/Female(Hembra)<please circle one>

 

 

 

 

 

 

 

 

 

Diagnosis(Diagnostico)__________________________

 

 

 

 

Medical Treatment(Tratamiento Medico) ______________________________________________

 

Reason for Referral__________________________________________________

 

 

(Motivo de la Referencia)

 

 

 

 

 

 

SPECIALITY(ESPECIALIDAD):

Pediatrics(Pediatria) Gen. Medicine(Gral. Medicine) OB/GYN Cardiology(Cardiologia)

(please circle one)

 

Opthamology(Oftalmologia) Diabetes(Diabetis) Internal Medicine(Medicina Interna)

 

 

 

Urology(Urologia) Dental(Dentista) Orthopedics(Ortopedia) Other(Otro)____________

 

 

 

 

 

 

 

 

 

Signature of Referring Doctor_________________________________

 

 

 

 

(Firma del Doctor de la Referencia)

 

 

 

 

 

 

 

 

 

Hospital General El Buen Samaritano

 

 

 

 

 

 

 

Surgical Referral from Batey Clinic

 

 

 

 

 

 

(Referencia Quirurgica del Operativo Medico)

 

 

 

 

 

 

 

 

 

 

 

Date (Fecha)_________

 

Batey/Barrio_________________

 

 

 

Name of Referring Doctor (please print)__________________________

 

 

 

(Nombre del Doctor de la Referencia)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Name___________________________

 

Age(Edad)___

 

 

(Nombre del Paciente)

 

 

 

Male(Hombre)/Female(Hembra)<please circle one>

 

 

 

 

 

 

 

 

 

Diagnosis(Diagnostico)__________________________

 

 

 

 

Medical Treatment(Tratamiento Medico)______________________________________________

 

Surgery Needed_________________________________

 

 

 

 

(Necesidad Quirurgica)

 

 

 

 

 

 

SPECIALITY(ESPECIALIDAD):

Pediatrics(Pediatria) Gen. Medicine(Gral. Medicine) OB/GYN Cardiology(Cardiologia)

(please circle one)

 

Opthamology(Oftalmologia) Diabetes(Diabetis) Internal Medicine(Medicina Interna)

 

 

 

Urology(Urologia) Dental(Dentista) Orthopedics(Ortopedia) Other(Otro)____________

 

 

 

 

 

 

 

 

 

Signature of Referring Doctor_________________________________

 

 

 

 

(Firma del Doctor de la Referencia)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospital General El Buen Samaritano

 

 

 

 

 

 

 

Surgical Referral from Batey Clinic

 

 

 

 

 

 

(Referencia Quirurgica del Operativo Medico)

 

 

 

 

 

 

 

 

 

 

 

Date (Fecha)_________

 

Batey/Barrio_________________

 

 

 

Name of Referring Doctor (please print)__________________________

 

 

 

(Nombre del Doctor de la Referencia)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Name___________________________

 

Age(Edad)______

 

 

(Nombre del Paciente)

 

 

 

Male(Hombre)/Female(Hembra)<please circle one>

 

 

 

 

 

 

 

 

 

Diagnosis(Diagnostico)__________________________

 

 

 

 

Medical Treatment(Tratamiento Medico)_____________________________________________

 

 

 

 

 

 

 

 

 

 

Surgery Needed_________________________________

 

 

 

 

(Necesidad Quirurgica)

 

 

 

 

 

 

SPECIALITY(ESPECIALIDAD):

Pediatrics(Pediatria) Gen. Medicine(Gral. Medicine) OB/GYN Cardiology(Cardiologia)

(please circle one)

 

Opthamology(Oftalmologia) Diabetes(Diabetis) Internal Medicine(Medicina Interna)

 

 

 

Urology(Urologia) Dental(Dentista) Orthopedics(Ortopedia) Other(Otro)____________

 

 

 

 

 

 

 

 

 

Signature of Referring Doctor_________________________________

 

 

 

 

(Firma del Doctor de la Referencia)

 

 

 

 

 

 

 

 

Hospital General El Buen Samaritano

 

 

 

 

 

 

Calle Circunvalacion #79, Alto de Villa Verde, La Romana, R.D.

 

 

 

 

Telefono: 550-0022

 

 

 

 

 

 

 

Referral for Tubal Ligation (Referencia para Salpingo)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Name:_________________________

 

Batey/Barrio__________________

 

 

(Nombre del Patiente)

 

 

 

 

 

 

 

 

 

 

 

 

 

House#:________

 

 

 

 

 

 

 

 

(Numero de la Casa)

 

 

 

Date for Lab Analysis:__________________

 

 

 

 

 

 

(Fecha para los Analysis antes de la cirujia)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Schedule for the week of:________________

 

 

 

 

 

 

(Fijar para la semana de:)

 

 

 

 

 

 

 

 

 

 

 

Hospital General El Buen Samaritano

 

 

 

 

 

Calle Circunvalacion #79, Alto de Villa Verde, La Romana, R.D.

 

 

 

Telefono: 550-0022

 

 

 

 

 

 

Referral for Tubal Ligation (Referencia para Salpingo)

 

 

 

 

 

 

 

 

 

 

 

 

Patient Name:_________________________

 

Batey/Barrio__________________

 

(Nombre del Patiente)

 

 

 

 

 

 

 

 

 

 

 

 

House#:________

 

 

 

 

 

 

 

(Numero de la Casa)

 

 

Date for Lab Analysis:__________________

 

 

 

 

 

(Fecha para los Analysis antes de la cirujia)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Schedule for the week of:________________

 

 

 

 

 

(Fijar para la semana de:)

 

 

 

 

 

 

 

 

 

 

Hospital General El Buen Samaritano

 

 

 

 

 

Calle Circunvalacion #79, Alto de Villa Verde, La Romana, R.D.

 

 

 

Telefono: 550-0022

 

 

 

 

 

 

Referral for Tubal Ligation (Referencia para Salpingo)

 

 

 

 

 

 

 

 

 

 

 

 

Patient Name:_________________________

 

Batey/Barrio__________________

 

(Nombre del Patiente)

 

 

 

 

 

 

 

 

 

 

 

 

House#:________

 

 

 

 

 

 

 

(Numero de la Casa)

 

 

Date for Lab Analysis:__________________

 

 

 

 

 

(Fecha para los Analysis antes de la cirujia)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Schedule for the week of:________________

 

 

 

 

 

(Fijar para la semana de:)