Health Referral System Manual - Health Referral Manual

HEALTH REFERRAL
SYSTEM MANUAL
Republic of the Philippines

Department of Health
Integrated Community Health Services Project (ICHSP)
San Lazaro Compound, Rizal Avenue, Santa Cruz, Manila
Monitoring and
Evaluation Tool
For
Health Care
Financing
This Manual was prepared by the Department of Health through the Integrated
Community Health Services Project (ICHSP) in cooperation with the Health Policy and
Planning Bureau (HPDPB) and Bureau for Local Health Development (BLHD) with
support from the Asian Development Bank (ADB), for the use of the Local Government
U it (LGU )
Local Health Referral System
TABLE OF CONTENTS
FOREWORD
iii
ACKNOWLEDGMENTS
iv
LIST OF FIGURES
LIST OF ABBREVIATIONS AND ACRONYMS
vi
I.
INTRODUCTION
II.
THE REFFERAL SYSTEM

Definition of a Functional Referral System
Types of Referrals
Framework for Referral System
Requisites for a Functional Health Referral System
2
2
3
3
5
III.
OPERATIONALIZING THE HEALTH REFERRAL SYSTEM

Steps in Setting-up a Referral System
Referral System Flow Chart
Referral Procedure
8
8
10
10
IV.
THE PATIENT AND HEALTH CARE SERVICES

Essential Health Services/Minimum Packages of Activities
Categories of Health Providers and Levels of Care
Standard Profiles of Health Facilities and Health Personnel
14
14
19
20
V.
MONITORING AND EVALUATION
26
VI.
RELEVANT POLICIES AND GUIDELINES

General Policies
Institutional Policy/Guidelines
Procedural Guidelines
Health Referral Management Activities
Support Mechanisms
Policies on Medico-legal Cases
Importance of Case Management Protocols
28
28
29
29
30
30
31
32
VII.
SUMMARY AND CONCLUSION
33
ANNEXES
34
Annex A
35
Specific Tasks at Different Levels of Facility

Inter-Health Facility Referral System
BHS Level
RHU Level
Hospital Level
Tertiary Level/Specialty Hospital
i
Intra-Health Facility Referral System

Intra-RHU Programs/Special Projects
Intra-Hospital Referral
Annex B
Clinical Records and Referral Slips

Monitoring Form for Incoming Referrals
Monitoring Form for Outgoing Referrals
Quarterly Report Form for Incoming Referrals
Quarterly Report Form for Outgoing Referrals
Top Ten Leading Referred Cases
Intra Health Facility Referral Slip
Inter Health Facility Referral Slip
Pro-forma Discharge Summary
Pro-forma Consent Slip for Referral
Annex C
Sample Treatment Protocol
53
Annex D
Directory of Participants
57
GLOSSARY
59
REFERENCES
60
ii
FOREWORD
This Manual was developed to serve as a guide in setting-up the referral
system in the devolved health facilities. It shall provide the health workers with
a common framework to effectively operate the health referral system.
The health referral system described in this Manual shall enhance the
operation of the Inter-Local Health Zone (ILHZ) System and the Sentrong
Sigla Program of the Department of Health (DOH). The standard criteria and
procedures in this Manual were based on the guidelines of DOHs Bureau of
Health Facilities and Services (BHFS), National Center for Health Facility
Development (NCHFD), and public health programs. It also considered the
World Health Organization (WHO) guidelines on health referral systems and
the experiences of health personnel relative to the efficient and effective
delivery of health services to the population.
This document, developed in collaboration with specialists, experts, and
users of health referral systems, is for the benefit of new public health
practitioners.
iii
ACKNOWLEDGMENTS
The Project Management Team extends its appreciation to the participants
and resource persons of the workshop for their valuable contribution in the
development of this Manual. The lively discussions, suggestions, and
experiences were used as inputs to make the Manual very practical for public
health practitioners.
The development of this Manual was made possible through the
Integrated Community Health Services Project (ICHSP) and the National
Center for Health Facility Development (NCHFD).
Recognition and appreciation is also extended to the following NCHFD
staff for their additional research, contribution, and editorial services:
Dr. Robert S. Enriquez, Division Chief
Ms. Madelene Gabrielle M. Doromal, Medical Social Work Adviser
Dr. Melecio Dy, Medical Specialist IV.
iv
List of Figures
Figure no.
1
2
3
4
Title
Operational Framework: Comprehensive Two-way
Referral System
Conceptual Framework of the Referral System
Standard Referral System Flowchart
Inter-Local Health Zone Referral System
Page
6
7
12
13
List of Abbreviations and Acronyms

AGE
Acute Gastroenteritis
ARI
Acute Respiratory Infection
BCG
Bacillus Calmette Guerrin
BFAD
Bureau of Food and Drugs
BHFS
Bureau of Health Facilities and Services
BHS
Barangay Health Station
BHW
Barangay Health Worker
BSMP
Blood Smear for Malarial Parasites
CBC
Complete Blood Count
CDD
Control of Diarrhea Diseases
CPG
Clinical Practice Guideline
CVD
Cardio-Vascular Diseases
DHS
District Health System
DOH
Department of Health
DPT
Diptheria Pertussis Tetanus
DR
Delivery Room
EPI
Expanded Program on Immunization
ER
Emergency Room
FP
Family Planning
GO
Government Organization
vi
HEPO
Health Education and Promotion Officer
HRS
Health Referral System
ICHSP
Integrated Community Health Services Program
IEC
Information, Education, and Communication
IHW
Institutional Health Worker
ILHZ
Inter-Local Health Zone
LGC
Local Government Code
LGU
Local Government Unit
MHC
Main Health Center
MHO
Municipal Health Officer
MO
Medical Officer
MSW
Medical Social Worker
MT
Medical Technologist
NBI
National Bureau of Investigation
NGO
Non-Government Organization
OPD
Out-patient Department
PHC
Primary Health Care
PHN
Public Health Nurse
PHO
Provincial Health Officer
PO
Peoples Organization
PS
Provincial Sanitaria
RHM
Rural Health Midwife

vii
RHP
Rural Health Physician
RHU
Rural Health Unit
RSI
Rural Sanitation Inspector
STD
Sexually Transmitted Disease
UTI
Urinary Tract Infection
WHO
World Health Organization
viii
I.
INTRODUCTION
The implementation of the 1991 Local Government Code (LGC) broke

the chain of integration of the health care delivery system. It brought about
a two-tier health care delivery system wherein hospital and public health
services are administered independently by the provincial and municipal
governments. Moreover, municipalities began operating separately from
each other, resulting to the further segregation of the public health system
within the province. Furthermore, optimal national and local interface
became a problem in the implementation of public health programs.
Consequently, this fragmentation of local health services resulted to the
deterioration of integrative approaches to health care delivery system and
quality of local health care services. These services include the
management of the referral system, which by its very nature requires good
coordination and cooperation in the delivery of health services at all levels.
(Health Sector Reform Agenda Monograph #2 Series Dec. 1999)
During the writeshop of this Manual in December 2001, the following
were identified as deterrents to the implementation of a functional referral
system:
Inadequate policies and guidelines on the referral system;

Poor accessibility due to geographical location;
Inadequate health human resources;
Inadequate logistics and technical support; and
Poor knowledge, attitudes, and skills among health providers.
Under Section 33 of the implementing rules and regulations of the Local

Government Code, DOH is mandated to install mechanisms for the
integration of health services, such as, referral and networking systems. In
response to this challenge, the DOH, through its Integrated Community
Health Services Project (ICHSP) and the National Center for Health Facility
Development (NCHFD), worked on the development of this Manual to
strengthen the referral systems.
Strengthening the health referral system would upgrade the health care
facilitys quality of health services, optimize the use of available state of the
art equipment, and enhance its capabilities in local health planning,
decision-making, and monitoring.
1
1
II.
THE REFERRAL SYSTEM
1.
Definition of a Functional Referral System
Section 33 of the rules and regulations implementing the Local

Government Code, defined a functional referral system as one that
ensures the continuity and complementation of health and medical
services. It involves all health facilities from the lowest to the highest level.
These services shall be comprehensive and shall encompass promotive,
preventive, curative, and rehabilitative care.
For the purpose of this Manual, referral shall refer to the set of activities
undertaken by a health care provider or facility in response to its inability to
provide the necessary medical intervention to respond to a patients need,
whether real or perceived. It is a regular daily activity of linking a patient to
a needed service.
In its wider context, referral shall encompass referrals all the way from
the community to the highest level of care, and back (i.e., two-way referral);
and referrals within a health facilitys internal system. It also involves not
only direct patient care but support services as well (e.g., knowing where to
get a transport facility to move the patient from one facility to another).
Referral system is the mechanism whereby clients of local health
networks are managed and moved between various components of that
network. In particular, this relates to referral of patients from the health
center of first contact and the hospital at first referral level, and back again,
following completion of hospital intervention.
On the other hand, networking is a process, a concept, and a technique
that creates awareness, builds alliances, and pools resources of different
organizations. It is a means toward advancing an organizations goals or
agenda and optimizing / mobilizing its resources. To be effective and
successful, the networking system should have the following preconditions:
Complete trust and mutual respect among the members and

willingness to cooperate with others on equal terms;
Equal sharing of responsibilities and workload based on
organizational or individual capacities and mandates;
Equal access to resources;
Pragmatic and realistic approach to the implementation of
network activities; and
Strong emphasis on local or horizontal mobilization.
2
2
2.
Types of Referrals
Referrals may be internal or external.
A. Internal referrals are those which take place within the health facility
and from one health personnel to another (i.e., doctor to doctor,
resident to specialist, or nurse to MHO). Reasons for referral may
vary and may be any of the following:
Opinion or suggestion;
Co-management; and
Further management or specialty care.
B. External referral refers to the referral of patients from one health

facility to another.
1. Vertical
- patient referral may be from a lower to a higher

level of health facility and vice versa, based on the
role and responsibility of each category of health
facility.
2. Horizontal - patient referral is between like facilities in different
catchment areas.
3.
Framework for Health Referral System
The referral system shall operate within the framework of the Inter-Local
Health Zone (ILHZ). In the ILHZ concept, a referral system is often called
two-tiered since it involves mainly (1) the barangay health station, rural
health facility, and primary referral hospital (municipal hospital) which
provides primary medical care, and (2) a core referral hospital (district
hospital) which provides secondary care. In situations where a provincial
hospital falls within an ILHZs coverage area, the provincial hospital will act
as the core referral hospital. A referral within the ILHZ will only be as strong
as the weakest link in the chain of health facilities.
The linkages and lines of administrative communication / supervision
shall be managed by an ILHZ manager or its equivalent (a concurrent
capacity agreed upon by the members of ILHZ Board) and likewise,
administratively linked to the Provincial Health Office (PHO). The details of
such an organizational set-up will be one of the issues decided upon by the
local chief executives.
The movement of people through the health system from the first
contact to the first referral hospital will depend on the referral mechanism.
For the referral system to function well, competent personnel should be
assigned at the lower levels, especially the health centers, with
3
3
clearly defined roles and functions to avoid duplication of services. This is

to ensure that the range of services that need to be delivered are in fact
delivered. Self-referral based on perceived inadequacy in the lower levels
will perpetuate the vicious cycle of self-referrals to over-burdened and
under-staffed hospitals and lead to under-utilized health centers. To
address this issue, an advocacy program should be in place to inform and
motivate the general public to support the referral system.
It is important for health centers to refer only those patients for whom
secondary or tertiary care is essential. In general, referral from a health
center to higher levels should occur in the following situations:
When a patient needs expert advise;

When a patient needs a technical examination that is not
available at the health centers;
When a patient requires a technical intervention that is beyond
the capabilities of the health center; and
When a patient requires in-patient care.
For the referral system to be truly functional, the different levels of

health service delivery system must adhere to a set of guidelines based on
the ILHZ approaches to referrals. These guidelines are important since
they will govern the reason(s) why a patient needs to be referred to another
health facility. Outside of these guidelines, there should be a very strong
reason for bypassing the lower links in the health care delivery system.
The hospital, on the other hand, shall ensure that referrals coming from
health centers receive prompt attention. A referral back to the health center
shall also be done as soon as the reason for referral to the hospital has
been addressed. Such a system shall ensure that a two-way
communication is established. Referral is a two-way process that involves
cooperation, coordination, and information transfer between the health
centers and the hospitals.
Ultimately, the hospital will benefit from its strong involvement and
collaborative cooperation with the health centers, especially in managing
diseases whose causes have bearings on the public health system.
It is envisioned that the ILHZ or its equivalent, shall provide the
framework of integration for multi-sectoral collaboration (e.g., NGOs, POs,
and other GOs). It shall also be responsible for developing an integrated
and comprehensive ILHZ development plan, through participatory strategic
planning.
Lastly, the health referral system shall facilitate the integration of
curative and preventive services and shall likewise facilitate the integration
of the public and private health sector.
4
4
4.
Requisites for a Functional Health Referral System:
A well-functioning comprehensive two-way referral system shall have

the following:
1.
2.
3.
4.
5.
6.
7.
8.
Defined functions and responsibilities (i.e., service mixes for

each level of care);
Identified health service delivery outlets (public and private)
and services provided;
Agreed roles and responsibilities of key stakeholders;
Agreed standard case management protocols (treatment
protocols and guidelines);
Agreed referral policies, protocols, and administrative
guidelines to support the health referral system;
System to supervise, monitor, and evaluate quality of care,
referral practices, and support mechanisms;
Facilities and health workers capable in implementing the
health referral system; and
Core referral hospital should have at least four major
services: Medicine, Surgery, Pediatrics, and Ob-gyn. It shall
also have ancillary services (e.g., laboratory, x-ray).
5
5
Figure 1
Operational Framework: Comprehensive Two-Way Referral System
PRIMARY
PRIMARY HEALTH
HEALTH CARE
CARE (3RD
(3RD LEVEL
LEVEL
Community
BHS
RHU
MUNICIPAL/
DISTRICT
HOSPITAL
PROVINCIAL
HOSPITAL
MEDICAL/
REGIONAL
CENTER
PRIMARY
HEALTH CARE
( 1st LEVEL )
PRIVATE
HOSPITAL
PRIMARY
HEALTH CARE
(2ND LEVEL)
PRIMARY
HEALTH CARE
(3RD LEVEL)
SECONDARY
HEALTH CARE
TERTIARY
HEALTH CARE
(4TH LEVEL)
TERTIARY
HEALTH CARE
(5TH LEVEL)
Legend:
Standard Referral Flow
the usual route of referral
Alternative Referral Flow
the referral route taken
on exceptional cases
Figure 2
Conceptual Framework of the Referral System
TH
Pvt. Hosp.
Pvt. Hosp.
DH
DH
DH
RHU
RHU
RHU
Pvt. Clinic
Pvt. Clinic
BHS
Community
ILHZ
Legend:
TH
DH
RHU
BHS
Pvt. Hosp.
Tertiary Hospital
District Hospital
Rural Health Unit
Barangay Health Station
Private Hospital
III.
OPERATIONALIZING THE HEALTH REFERRAL SYSTEM
1.
Steps in Setting-Up a Referral System

A.
Organizing the Referral System
The Provincial Health Officer (PHO) should initiate the idea of setting up
a referral system with technical support from the DOH. Key individuals from
different health facilities should also be involved.
For the referral system to work, it is assumed that an Inter-Local Health
Zone (ILHZ) or its equivalent is in place, and that the ILHZ board or
committee has been organized. In the absence of the latter, a task force
can be created to spearhead the project. The task of the ILHZ board is to
conduct a situational analysis on the current state of health care in the
proposed operational area. A good model is to use strategic planning as a
tool to see where you are and where you want to go in terms of the
referral system.
B.
Planning for a Comprehensive Referral System
Preparatory Phase
If the ILHZ is not yet organized, seek a mandate from the

local chief executives.
Prepare a Memorandum of Understanding (MOU) /
Memorandum of Agreement (MOA) among the
stakeholders. This serves as the commitment among the
participating agencies and ensures that all the parties
involved follow the agreements.
Hold a meeting with the stakeholders to be attended by
the chief or administrators of the health facilities within the
geographic area. The objective of the meeting is to
assess the situation in the participating health facilities,
identify the health services to be improved, address
prevalent cases, and identify the needed drugs and
medicines that should always be made available.
Draw a map of the facilities involved to determine the
geographic boundary and the participating facilities. The
main purpose is to identify the levels of care available and
validate the information provided during the meeting of
stakeholders.
Assign the responsibility of operationalizing the referral
system under the technical committee of the ILHZ.
8
8
Planning and Implementation Phase
C.
Prepare or review existing strategic and operational

integrated health plans.
Conduct planning workshops to delineate the
responsibilities of each referral level in the implementation
of the referral system to include a monitoring system to be
participated in by the stakeholders.
Conduct periodic evaluation and refining of the system.
Prepare a handbook on the referral system specific for the
ILHZ or its equivalent.
Documentation
This involves going through the process of identifying the requisites of a

referral system and everything that goes with the system to make it work. It
is necessary that all the relevant issues are threshed out and that
corresponding policies and guidelines are in place. Considering the
uniqueness of each health facility, no canned referral system can really
work. It should be made to fit the needs and resources of the locality.
Innovations are also encouraged. The handbook shall contain the following:
I.
II.
Introduction
Operation of the Health Referral System
1. Policies and guidelines
Point persons from each member facility;
Referral structure;
Use of transport vehicles;
Referrals during off-hours and holidays;
Medico-legal cases;
Cross-boundary referrals;
Use of referral notes / standards forms;
Budgetary support;
Fees (e.g., charges on use of facilities);
Settling disputes, controversies;
Monitoring and evaluation;
Regular review of policies and guidelines;
Human resource / skills development programs; and
Others.
2. Flowchart of facilities within the referral network
III.
Health care resources for the referral system

1.
2.
3.
List of health care facilities with corresponding roles;

Essential health care services or minimum package of
activities; and
List of health personnel.
9
9
IV.
Monitoring and Evaluation
V.
Standard Forms Used in the Referral System
D.
Promotion of the Health Referral System
The promotion of the health referral system need not be a fancy event.
This can be done in the form of an orientation meeting to inform all those in
the ILHZ of the existence of such a system, and how it works.
Eventually, the community should be informed. This activity must be
included in the communication plan of the ILHZ.
E.
Sustaining a Functional Referral System
Regular and periodic monitoring should be conducted. Ideally, there

should be a point person whose job is to address the day-to-day problems
encountered. Annual reviews should also be part of the activities to ensure
that policies and procedures are appropriately updated with changes in the
environment and advances in technology. Finally, a conscious effort should
be exerted towards human resource development to ensure quality of care.
2.
Referral System Flow Chart
There are several factors that affect the flow of a health referral system.
It depends on the geographical location, competencies of health personnel,
availability of supplies, health facility capability, and the customs and
practices of the people.
Because of these factors, the flowchart of the referral system should be
followed, to minimize, if not, avoid delays. Following the flowchart can also
prevent the duplication of services.
3.
Referral Procedure
A.
Patients coming from a referral facility shall bring with them a

referral slip / note containing relevant information, such as:
Pertinent history focusing on significant facts, family history, and

past illnesses;
Problem or complaint, impression / diagnosis and interventions
given (e.g., home / facility);
Instruction(s) or advice(s) given after consultation;
If observed or confined in the referring facility (hospital-RHU),
include course of the illness; and
Reason(s) for referral.
10
10
B.
Once the reason(s) for the referral has been addressed, the
patient shall be referred back with a corresponding return
referral slip containing the following:
Diagnosis;
Diagnostic interventions, if any;
Therapeutic interventions;
Condition upon discharge;
Instructions / advices given;
Activities to be undertaken by the receiving health facility; and
Discharge summary, if confined in a hospital.
C.
All referrals shall be recorded both by the referring and

receiving health facilities. This vital information is needed for
policy formulation and improvement of the quality of services
rendered.
D.
Patients shall be referred after the following have been

satisfied:
Assessment of patient has been done;

Decision as to who shall accompany the patient (e.g., nurse or
doctor);
Availability of transportation / ambulance; and
Facility to be referred has been identified.
11
11
Figure 3
Standard Referral System Flowchart
Community
BHS
RHU/CHO
Municipal/City/
District/
Private Hospital
Provincial/Private
Hospital
Regional
Hospital
Medical Center
& Specialty
Center
12
Figure 4
Inter-Local Health Zone Referral System
Community
BHS/RHU/CHO
Private Clinics
District Hospital/
City Hospital/
Private Hospital
Provincial
Hospital
IV.
THE PATIENT AND HEALTH CARE SERVICES
1.
Essential Health Services / Minimum Packages of Activities
A minimum package of health services is necessary to ensure that

limited resources are maximized and not wasted. Such services will
subsequently be assigned to the health facilities as either their primary or
secondary responsibilities. Examples of such services are hereunder listed.
A.
Public Health Services (Primary Care BHS) in these

instances may include the following: (Check box if available in
your facility)
Immunization
_ BCG
_ DPT
_ OPV
_ Measles vaccine
_ Hepatitis B Vaccine
_ Tetanus Toxoid
_ Anti-rabies vaccine
_ Others _______________________________
Family Planning/ Reproductive Health
_ Couples Education (IEC)
_ Family Planning Methods
Nutrition Services (include growth monitoring)
_ Operation Timbang
_ Food/ Nutrition Supplementation
_ Micronutrients supplementation
_ Others _______________________________
Essential individual clinical services
_ Maternal and Child Health
_Prenatal
_Childbirth
_Post-partum
_ Common illnesses
including:
_ Diarrhea
_ ARI
_ Measles
_ Dengue
14
_ Malnutrition
_ Other endemic diseases of the area
(e.g., Schistosomiasis)
_ Malaria
_ Non-communicable disease prevention program
_ Degenerative diseases (Pls. specify)__________
_ CVD Program (Hypertension, RHD)
_ Cancer prevention & control
_ Communicable disease prevention program
_ Tuberculosis
_ Leprosy
_ Rabies control
_ Others _______________________________
B.
Public Health Services (Primary Care RHU) in these

instances may include the following: (Check box if available in
your facility)
Immunization
_ BCG
_ DPT
_ OPV
_ Measles vaccine
_ Hepatitis B vaccine
_ Tetanus toxoid
_ Anti-rabies vaccine
_ Others _______________________________
School-based services
_ Reproductive health education and information
_ Smoking, alcohol abuse, and drug dependence
_ Mental and oral health
_ Others _______________________________
Occupational Health
_ Pre-employment examination
_ Annual Physical Examination
_ Health education
15
Reproductive Health
_ Education
_ STD
_ Family planning methods
_ Violence against women/children (e.g. rape, domestic
violence)
_ Others _(e.g., pap smear, gram stain)
___________________________
Medico Legal Services
o Post Mortem Examination / Autopsy
o Physical examination
o Court representation
Nutrition Services (include growth monitoring)
_ Operation Timbang
_ Food/ nutrition supplementation
_ Malnutrition related diseases identification
_ Micronutrients supplementation
_ Others _______________________________
Environmental Health Protection
_ Sanitation
_ Food safety
_ Safe water supply
_ Safe housing
_ Others _______________________________
Basic Laboratory Services:
_ Urinalysis
_ Blood Smear for Malarial Parasite (BSMP)
_ CBC
_ Blood typing
_ Pregnancy test
_ Stool examination
_ Sputum examination
_ Others ___________________
Minor Surgeries
_ Circumcision
_ Non-life threatening injuries
_ Others ___________________
C.
Hospital Services (secondary and tertiary care): Hospital

should provide inpatient care and diagnostic workup for
possible referral to higher levels of care.
16
This shall also include current hospital initiatives like the hospital as
center of wellness, breastfeeding, etc. At the minimum, district hospitals
should have the capability to respond to life-threatening surgical
emergencies, such as, chest injuries requiring tube insertion, ruptured
appendicitis, etc. The hospital should have the necessary expertise and
facilities to be able to respond to all of these. (Check box if available in your
facility): Hospital Standards and Technical Requirements (Please refer to
DOH AO # 70-A S2002 for the complete listing):
1. Services Capabilities:
Clinical / Medical Services
Basic Services
_ Surgery
_a. Major __________________________________
_b. Minor __________________________________
_ Pediatrics
_ Ob-Gyn
_ Internal Medicine
_ Dental Service
_ Emergency Service
_ Out-patient Service
_ General Anesthesia (secondary level)
_ Clinical core (secondary level)
Medical Ancillary Services
Anesthesia
Radiology
Laboratory
Pharmacy
Nursing Services
2. Technical Requirements:
Personnel
Administrative service
_ a. Chief of Hospital
_ b. Administrative Officer
_ c. Accountant
_ d. Bookkeeper
_ e. Cashier
_ f. Statistician
_ g. Admitting Clerk
_ h. Medical Record Officer
_ i. Medical Social Worker
17
_ j.
_ k.
_ l.
_ m.
_ n.
_ o.
_ p.
_ q.
_ r.
Dietician, Nutritionist
Cook
Food Service Worker
Building Maintenance
House Keeper
Storekeeper
Laundry worker
Utility worker
Driver
Clinical / medical
_ a. Chief of Clinics
_ b. Medical Specialists in the following fields:
_ Surgery
_ Radiology
_ Anesthesiology
_ Ob-Gyn
_ Pediatrics
_ ENT
_ Pathology
_ Internal Medicine
Ancillary
_ a. Radiology Technician
_ b. Medical Technologist
_ c. Pharmacist III / II
Nursing
_ a. Nurse IV / III / II / I
_ b. Nursing Attendant
Equipment/ Instruments (per area)

ER
OPD
OR/DR
Nursery
Wards
Dietetic Area
Hospital Maintenance
Physical Facilities
Administration
Clinical Service
18
Nursing
Dietetic
Maintenance, Engineering, and Housekeeping
2.
Categories of Health Care Providers and Levels of Care
The range of services demands that there should likewise be a

corresponding range of health care providers. Manpower complement
could thus be assigned to the level of service, depending on the complexity
of care required. (Check manpower complement if available)
A.
Community Based Health Services / Home Remedies:
This group, which will extend services, such as, screening and follow-up
of cases and undertake IEC activities, shall be composed of the following
personnel:
B.
Family or Family Health Aide;

Community-based Physical Rehabilitation Aide;
Barangay Health Workers (interface between community and
RHU);
Barangay Nutrition Scholars;
Microscopist (sputum collection, BSMP);
Other traditional healers & midwives (hilots, herbolarios); and
Others __________________________________
Public Health Services
Barangay Health Stations

o
Midwife
o
BHW
o
Traditional Birth Attendant
Rural Health Unit (RHU) provides essential public health

services, such as those listed above. It shall also provide
individual clinical services especially for minor ailments, trauma,
and accidents.
o
o
o
o
o
o
o
o
o
Rural Health Physician / Municipal Health Officer

Dentist
Public Health Nurse
Sanitary Inspectors
Medical Technologist
Laboratory Technician
Health Educator/ Community Organizer/ Liaison
Support staff
Others __________________________________
19
C.
Hospital Services
A hospital includes appropriate laboratory, diagnostic, and logistical

support services. It should at least have the capability to respond to lifethreatening conditions and provide basic life support system. Its manpower
complement shall be appropriate and commensurate to the service
required, ideally, with secondary care capability.
3.
Standard Profiles of Health Facilities and Health Personnel

A.
Facilities and Services
Health services are traditionally described as curative and preventive,

with the former provided by the hospital system, and the latter by the public
health system. The standard description of each facility is presented
below.
Standard Description of Hospitals
1.
Provincial Hospital
The standard provincial hospital is a tertiary referral hospital with at

least 75 beds and services the whole province. Hence, every province
shall have at least one provincial hospital.
To enable the hospital to
perform its functions effectively, it shall be provided with communication
linkages and transport services.
The provincial hospital provides departmentalized specialty level
diagnosis and management of cases in the fields of internal medicine,
pediatrics, ob-gyn, and surgery. It handles emergency cases, out-patient
consultations, in-patient care, referred cases, and rooming-in services. It
also provides training programs and limited residency training. Nursing
services are departmentalized in this level.
Ancillary facilities found in provincial hospitals include laboratory for
routine microscopy, hematology, chemistry, blood banking, and autopsy;
radiology equipment; OR-DR, and premature nursery; heart station, dietary,
pharmacy, records and supply rooms, etc. Administrative, maintenance,
engineering support, and quarters for doctors and nurses are also standard
facilities in the hospital.
A standard provincial hospital is authorized to have as many as 20 or
more physicians, 30 or more nurses / nursing attendants and 20 or more
administrative support staff. In addition, its plantilla includes a pharmacist,
midwife, nutritionist, radiologist, and medical technologist.
20
2.
District Hospital
The standard district hospital has a capacity of at least 25 beds and

services a catchment population of not less than 75,000. It is the core
referral hospital in the ILHZ. It provides frontline basic services in
medicine, surgery, ob-gyn, and pediatrics. These services, however, may
not necessarily be departmentalized.
The district hospital provides the venue for medical-surgical missions.
Ancillary services found at the district hospital are similar to those found
in the provincial hospital. The only difference in capability level is the
absence of specialty level medical diagnosis and treatment. Hence, the
hospital can only execute minor surgeries and serve as the first referral or
contact hospital for serious emergencies before these cases are
transferred to the provincial or other tertiary hospitals.
The usual district hospital would have a personnel complement of five
(5) physicians, eight (8) nurses, and five (5) administrative staff.
3.
Municipal / Medicare Hospital
While smaller than a district hospital, having a capacity of 10-15 beds

and a catchment area greater than 25,000, the municipal hospital has
almost the same capabilities as that of a district hospital except that it does
not have an OR. It can also serve as a venue for medical-surgical
missions. The medical staff of a municipal / Medicare hospital would be
three (3) doctors and five (5) nurses.
4.
Extension Hospital
This hospital is an outreach component of a regular hospital, usually the

provincial hospital, to service those coming from the remote areas of the
province. It can also be the venue for medical-surgical missions. Its inpatient capacity may be lower compared to the district or community
hospital while its diagnostic and treatment capability is limited to minor
urgent emergency cases. A concrete example of this is a hospital in
Buenavista, Guimaras that serves as an extension hospital of the Guimaras
Hospital located in Jordan.
Standard Description of Public Health Facilities
1.
Rural Health Unit (RHU)
The RHU is a municipal level health facility, although in large

municipalities like Tabuk, which has three RHUs, the facility may service
21
only a portion of the whole municipality. The focus of the RHU is

preventive and promotive health and the supervision of barangay health
stations under its jurisdiction.
The Municipal Health Officer (MHO) heads the RHU and is assisted by
the Public Health Nurse (PHN). It is the PHN who directly supervises the
Rural Health Midwives (RHMs) in running the BHS. Most RHUs are
provided with an ambulance, either purchased by the municipal
government or donated by an external source. Communication facilities,
which are critical in a health referral system, should be present.
2.
Barangay Health Stations (BHS)
The BHS is the first facility in the public health system. It is manned by
a cadre of volunteer BHWs (Barangay Health Workers) under the
supervision of the RHM.
The MHO normally conducts diagnostic
consultations and gives prescriptions and referrals on a regular basis in the
BHS. The BHWs are trained in preventive health care with a strong
emphasis on maternal and childcare, family planning and reproductive
health, nutrition and sanitation, as well as, prevention and care of common
diseases.
B.
Medical and Public Health Personnel
There are two types of human resources involved in the health delivery
system: the hospitalbased personnel and the public health personnel.
Following are the summary profiles of each type of key personnel:
Profiles of Hospital Personnel
1.
Medical Officer (MO) V / IV Chief of Hospital
As hospital chief, he / she exercises clinical and administrative

functions. As a physician, he / she examines, evaluates, and treats
patients. He / she also provides clinical supervision over physicians under
him, and attends to medico-legal cases (i.e., performing autopsy).
As hospital administrator, he / she leads in the development of the
annual hospital budget and logistics plan; monitors, reviews, and evaluates
the performance of staff and operating units of the hospital; and builds
positive networking with support institutions, NGOs, and the community.
2.
Medical Specialists
Provincial hospitals with 100 beds or more, have medical specialist

positions. The more common areas of specialization are surgery, internal
22
medicine, obstetrics-gynecology, and pediatrics. Medical specialists are the

technical resource persons of the hospital for difficult cases.
3.
Medical Officer (MO) III / II
The medical officers fall in mid-position in the ranks of hospital-based

physicians. As a rule, a medical officer performs purely medical services,
except when he / she is assigned as Officer-in-Charge of the hospital. The
MO III / II brings in new techniques and scientific information from clinicopathological conferences and seminars he / she have attended.
4.
Chief Nurse
He / she supervises the nursing staff and attendants; conducts staff

trainings, and coordinates nursing services with other hospital units. He /
she also handles the preparation of requisitions for supplies, materials, and
equipment; and the preparation of statistical reports, plans, and budgets.
5.
Nurse III / II
The intermediate categories of nurses are usually assigned to a nursing

station to supervise and assist nurses and aides under them to ensure the
quality of the nursing care provided to the patients. He / she prepares
requisitions for medicines, supplies, and equipment, and recommends
approval to the Nurse IV. He/ she accomplishes monthly statistical reports
on patients, requisitions, and medical stock assessment.
6.
Nurse I
Occupying the first rank in the nursing ladder, the Nurse I is the bedside
nurse who conducts ward rounds; administers medications according to
doctors orders; prepares patients records; assists the physician during
patient examination / treatment, provides information to the patient / family
regarding the patients condition, and supervises other hospital personnel,
particularly, nursing attendants and Institutional Health Workers (IHWs).
7.
Medical Technologist (MT)
The MT performs routine laboratory examinations for blood, urine, stool

and other serology tests; records and releases accomplished laboratory
results of patients undergoing diagnosis; and prepares monthly laboratory
reports.
23
8.
Pharmacist III / II
His / her primary function is to manage the hospital pharmacy. He / she

fills and dispenses drugs and medical supplies prescribed by the
physicians and dentists.
9.
Radiologic Technician
The technicians main responsibility is to take x-rays of patients in

support of the diagnostic work of the physician. He / she also maintains
radiology equipment. .
10. Hospital Administrative Officer
The Administrative Officer takes care of the financial and administrative
operations of the hospital which includes: planning, budgeting; personnel
management; accounting, records, procurements, and maintenance of
facilities and equipment.
11. Nutritionist / Dietician
The Nutritionist / Dietician provides services in the planning of patients
diets, and supervision of food marketing, cooking, and distribution. He /
she has to coordinate closely with the doctors in charge on the type of food
to be served for different cases confined in the hospital. The nutritionist
monitors kitchen activities, making sure that sanitation and hygiene is
observed during food preparation, in the cleaning and storage of utensils,
dishes and silverware, and in garbage disposal. He / she also ensures that
the kitchen operates within its budget.
12. Medical Social Welfare Officer (MSWO I)
A Medical Social Worker provides services that will meet the social
problems influencing the effectiveness of health and medical care. The
MSWO should have a keen understanding of the inter-relationship between
socio-economic and emotional factors affecting health and wholesome
family and community life.
Patient referral is an important function of the MSWO. The MSWOs
contribution to the referral system includes coordination with other
concerned agencies to ensure provision of concrete support (e.g., financial,
transportation) and social work clinical services (e.g., counseling) that will
address the psychosocial impact of the referral.
24
13. Dentist
A dentist is a professional person qualified to perform procedures in the
oral cavity in order to provide preventive, curative, and rehabilitation
services.
Public Health Personnel
1.
He / she heads the decentralized health services at the municipal level

and serves as administrator of the rural health unit, the primary health
facility in the area. As a community physician, he / she conducts
epidemiological studies / investigation, formulates health education
campaigns on disease prevention, and prepares and implement control
measures or rehabilitation plans. He / she also serves as the medico-legal
officer.
As health administrator, his / her functions include the preparation of the
municipal health plan and budget; monitoring the implementation of basic
health services, and management of the RHU staff.
2.
Public Health Nurse (PHN)
The PHN supervises and guides all rural health midwives (RHMs) in
the municipality. He / she handles the health records of the community,
including data on morbidity and mortality cases, program accomplishments,
etc. The PHN also prepares monthly and quarterly reports to the MHO.
3.
Rural Health Midwife (RHM)
The RHM manages the BHS and supervises and trains the BHW in the
community. He / she provides midwifery services and execute health care
to women of reproductive age including family planning counseling and
services. He / she conducts patient assessment and diagnosis for referral /
further management; performs health IEC activities, organizes the
community, and facilitates barangay health planning and other community
health services.
4.
Provincial Sanitarian (PS)
The PS monitors and reports environmental factors that may affect the
health condition of the community, such as, quality of water supply,
airborne and vector-borne diseases, industrial pollution, and the use of
pesticides in agriculture and household sanitation. He / she provides
training for local staff and the community on environmental sanitation and
control of diseases.
25
5.
Rural Sanitation Inspector (RSI)
His / her functions are directed towards ensuring a healthy municipality.

This entails advocacy, monitoring, and regulatory activities, such as,
inspection of water supply and unhygienic household conditions.
6.
Health Education and Promotion Officer (HEPO)
The HEPO is the point person for the health information, education,
communication activities among public officials and institutions, the private
sector, and the community. He / she acts as a resource person in
community-based promotional activities and in drafting media releases.
V.
MONITORING AND EVALUATION
The implementation of the referral system should be monitored and

evaluated periodically. It is important to determine the persons suitable to
generate referral reports. Such persons may be: the rural health midwife for
barangay health stations; the public health nurse or the rural health midwife
for the rural health units; and the emergency room nurse and ward nurse
on duty for hospitals.
Monitoring and evaluation reports shall be submitted to the area or
district health team, or to the Provincial Health Office where a Monitoring &
Evaluation Team has been organized to review and assess the conduct of
implementation. The mode of review is up to the discretion of the Team.
Random review and field visits should be conducted for validation. An
information system is developed to track movement of patients from health
facility or department (in case of intra-hospital referrals in tertiary hospital).
The following parameters and indicators can be used to gauge the
quality of the referral system:
Efficiency (cost of referral the referral should have the least

cost for the health facilities and clients);
Effectiveness (outcome the referral should address the
diagnostic and curative requirements, prevent complications or
worsening of the condition);
Accessibility (ease of referrals refers to the existing conditions
i.e., transportation, communication, etc. that would facilitate the
transfer and acceptance of the client);
Appropriateness (conformity with protocol the referral facility
makes justified referrals on a timely basis);
26
Responsiveness (refers to the ability of the receiving facility to

accept and manage referred clients); and
Good inter-personal relationship (number of actively participating
facilities).
The referral system shall be tracked down through records, such as

checklists, logbooks, and reports. In particular, important information shall
include the following: (see Annex B)
Number of Patients referred;

Reason(s) for referral;
Number and list of receiving hospitals;
Leading Diagnosis;
Return slips received;
Number of referrals received;
Reasons for referral;
Number and list of referring hospitals;
Leading diagnosis;
Return slips sent back; and
Source of referrals
Suggested INDICATORS to gauge functional referral systems may

include:
1.
Rate of referrals = number of referrals

OPD consultations
= Number of referrals
Number of in patients
2.
Case Mix = number of cause specific case/ total number of referred

cases;
3.
Ten leading causes of referral; and
4.
Ratio of referrals with return slips = number of referrals with return

slips/ total number of referrals
Reporting
The ILHZ or its equivalent shall analyze referral data, identify gaps, and
propose recommendation(s) to improve the referral system.
The ILHZ chief shall prepare a consolidated report and submit it to the
PHO.
27
VI.
RELEVANT POLICIES AND GUIDELINES
1.
General Policies
A.
A two-way referral system must be observed;
B.
Hospital and field health personnel are expected to maintain

proper decorum at all times in relating with patients, patients
relatives and co-employees;
C.
Supervisors shall orient and train all hospital and field health
personnel in the operations of the comprehensive referral
system, in the context of local area health zone;
D.
Coordination and teamwork among all health providers shall

serve as a common approach to attain goals and objectives;
E.
Services to be rendered to a patient shall depend on the

facilities, its capabilities, and manpower resources;
F.
Referral system shall take into consideration the general

welfare of the patient and the capabilities of facilities within the
system;
G.
Tasks at any level of health care facility shall be clearly

defined, mutually understood, and reasonably quantified.
Actual performance shall also be evaluated regularly;
H.
All patients shall be attended to immediately upon arrival,

giving preference to emergency cases / or seriously ill patients;
I.
Clear, written, health referral policies and guidelines shall be

available in all health facilities. Standard referral forms must
also be available at any given time; and
J.
Essential drugs and medicines shall always be available

in all health facilities.
28
2.
Institutional Policy/Guidelines
In conformity with the national policies, and with the concurrence of the
local health board, supporting issuances shall be available in the following
areas:
A.
Technical policies
B.
Administrative policies
3.
Accidents;
Gunshot wounds;
Stab wounds;
Action on rape case;
Alcohol verification;
Drug test policy;
Medical / physical exam; and
Conduct of Autopsy
a. Autopsy examination
b. Post-mortem examination
Networking of health facilities within the ILHZ;

Use of vehicle (e.g., ambulance);
Transport of patient;
Extension of services outside the catchment area;
Management of medico-legal cases;
Issuance of medical certificates;
Attendance to court hearing of medico-legal cases; and
Incentives for using appropriate facilities (higher user fees
for using inappropriate facilities)
Procedural Guidelines
Services not currently available shall be accessed from the next

level of care;
Patients who have been referred must be sent back to originating

facilities for follow-up and disposition;
Cluster barangays and municipal health care units refer patients

to the core referral hospital of the ILHZ where they belong,
unless services are not available in that area;
29
4.
Patients may be transported to and from health facilities using a

service ambulance or other means of transportation. Ambulance
fee must be determined by the ILHZ and charged based on the
patients capacity to pay;
Communication system must be in place to facilitate the referral;
In areas or ILHZ where there is no government hospital,

networking with private hospital facilities with available services
shall be developed;
Available services at each facility shall be determined and a

MOA between the private and municipal and provincial
government should be undertaken;
Continuous training and updating of capabilities of the health

service providers shall be of utmost consideration;
A separate logbook shall be maintained for monitoring and

evaluating records of all patients; and
Each level of health care unit shall have a list of essential

equipment.
Health Referral Management Activities

A.
Orient all stakeholders on the following:

1. Policies
2. Procedures
B.
Conduct Quarterly Meetings

1.
2.
3.
4.
Assess health referral activities / performance

Assess coordinative mechanisms
Assess procedures and guidelines
Review standard operating procedures (SOP) / service
packages
5. Resolve issues and concerns
5.
Support Mechanisms
On the BHS:
Orientation and training of BHWs, RHM on the system of referral

(why, where, what, who, when, and how);
30
Barangay council to provide means of referring patient (transport /

communication); and
Promote and advocate the referral system to the community
On the RHU:
Orientation of the RHU staff and local government officials;

Flowchart on patient referral; and
Provision of ambulance, support, and communication.
On the hospital:
Ambulance / Communication; and

Trained staff to handle the case
Adequate staff, facilities and other resources that support the system
should be considered. Referral shall be in the context of ILHZ.
6.
Policies on Medico-Legal Cases

A.
As a general rule, all MHOs shall act as medico-legal officers in

their municipality in the absence of the provincial medico-legal
officer;
B.
All requests for medico-legal examinations must be

accompanied by an official request from the police authorities
of the concerned municipality or barangay;
C.
Medico-legal requests not within the capability of the MHO

concerned should be referred immediately to the NBI together
with corresponding reasons for referral;
D.
In cases where the MHO of the area concerned is out-of-town

and after all efforts to locate him / her had been exhausted, the
MHO of the nearest municipality within the ILHZ must perform
the requested examination;
E.
All medico-legal cases shall be the responsibility of the MHOs,

unless the patient would require the services of the hospital for
further evaluation and treatment. During weekends and
holidays, the hospital can attend to medico legal patients;
F.
Transport vehicle to fetch the MHO must be provided by the

requesting parties concerned. If autopsy is conducted in a
private setting, the MHO should be escorted by a police officer;
31
7.
G.
Medico-legal fees shall be paid to the MHO based on the rates

provided by the Magna Carta for Public Health Workers. This
policy is, however, subject to the availability of funds and the
usual accounting and auditing rules and regulations;
H.
In some instances where there are no MHOs available in the

area or ILHZ concerned, the Provincial Health Officer may,
upon prior notice, direct any government physician, preferably
with expertise on the case, to perform the required
examination. This is, however, subject to the presentation of a
certification from the Office of the Local Chief Executive
concerned that the MHO is not available; and
I.
All other policies not included herein in relation to the abovementioned subject matter shall be referred to the Provincial
Health Officer for evaluation and approval and subsequent
inclusion in this general policy guideline on referral of medicolegal cases.
Importance of Case Management Protocol
The referral decision of an individual clinician is the heart of the referral

system.
Such decisions are based on his professional attributes,
knowledge of the health care system, and personal style. However,
advancements in diagnostic technologies and therapeutic modalities
demand that the physician keep up with these changes. Unfortunately,
majority of our health professionals have little time to critically appraise
these developments. Consequently, even if conditions are similar, patients
are exposed to wide variations in clinical care and to potential irrational
management.
This is the importance of case management / Clinical Practice
Guidelines (CPGs) to all health care providers. The use of protocols is an
approach to encourage good practice in the area of health referrals.
PhilHealth has consolidated CPGs of seven (7) diseases as guide for
treatment and costing. These diseases are: hypertension, community
acquired pneumonia, dyspepsia, dengue, AGE, UTI, and asthma. The
referral network system in the ILHZ should decide which among the case
management protocols is applicable in their locality and consistent with the
capabilities of their facilities. (Please see attached sample protocol on case
management).
32
The case management protocol should be part of the overall dynamic

process of medical audit. It should be regularly reviewed and adopted in
response to advances in knowledge and change in the organization of
care. They can focus on one part of the process of diagnosis and
treatment, such as, referral to a health facility or can encompass a number
of key aspects of patient management.
The case management protocol may contain the following:
a.
b.
c.
d.
e.
f.
g.
VII.
Justification for admission

Diagnostic Criteria
Treatment (Management)
Complication and Management
When to refer
Nursing Management
Others
SUMMARY AND CONCLUSION
The Manual of Health Referral System developed by the ICHSP and

NCHFD through a workshop / writeshop, was based on an exhaustive
review of existing literatures, the participants experiences and the
expertise of the resource persons, with inputs from the previous
consultants hired by the project. It is a practical manual for the use of the
Municipal Health Officers, Hospital Chiefs, and other health personnel in
the field. The system developed, was aimed at increasing the coverage of
local health service, thereby providing efficient, accessible, timely and
quality heath care, both at the RHU and hospitals.
33
ANNEXES
34
34
Annex A
Specific Tasks at Different Levels of Facility
INTER-HEALTH FACILITY REFERRAL SYSTEM

BHS Level
Responsibility
Patient (Old)
Patient (New)
RHM
1.a
1.b
1.b.1
Action
Presents ID card from RHM
Requests for ID card from RHM
Fills-up client card and issues ID card to
patient
2.
Registers patients name in the Client

Registry Book
3.
Gets vital signs and records findings, as

well as, client complaint and history
4.
If case is simple and within the capability of

the RHM, gives medication to the patient
5.
If patient needs further evaluation, refers to

the RHUs; prepares referral slip to include
clinical summary, medicines or supportive
measures given
6.
Logs patient in referral patient registry
7.a
Advises patient to go to the health facility

he/she is being referred to
If patient needs confinement, RHM
accompanies patient to the Hospital
(District/Provincial)
7.b
35
35

RHU Level (From RHM-RHU Level, Patient within RHU catchment area)
Responsibility
Patient from BHS
OPD Nurse
1.
2.
3.
MHO
4.
5.
6.
6.a.1
OPD Nurse
6.a.2
MHO
6.b
PHN
6.b.1
6.b.2
6.b.3
MHO
6.c.
6.c.1
PHN
6.c.2
6.c.3
6.c.4
6.c.5
7.
Patient
8.
Action
Presents BHS referral slip
Reviews referral slip, enters patients data
in client registry/logbook and referral
registry
Gets vital signs and records findings and
review clinical history
Refers patient to MHO
Reviews patients records, examines,
evaluates and treats patient
If case is simple, discharges patient.
Fills-out return referral slip to include
medications/ instruction to be undertaken
Records additional information in referral
registry
If patient was referred due to notifiable
disease, MHO conducts epidemiologic
surveillance and notifies his/her team to
undertake an examination/investigation
Enters patients data in notifiable diseases
registry and action undertaken
Re-enters additional data when the disease
surveillance has been done
Fills out return referral slip to include
instruction and actions to be undertaken
If patient needs further work-up and
confinement, prepares referral slip to
District/Provincial Hospital.
Enters pertinent data, actions undertaken
and reason for referral.
Records patients data in referral registry.
Advises patient to go to hospital and
arranges transport.
May accompany the patient to hospital
concerned, if needed.
Shall accompany emergency cases.
If not necessary, advises patient to proceed
to health facility concerned to give return
referral slip
Returns referral slip to RHM
36
36

Hospital Level (patient from BHS/RHU to District / Provincial Hospital)
Responsibility
Action
Patient/Patients Companion
OPD Nurse
1.
2.
3.
OPD Physician-in-charge
4.
5.
6.a.1
6.a.2
OPD Nurse
6.a.3
6.a.4
6.a.5
6.a.6
OPD Physician-in-charge
6.b1
Physician-in-charge
6.b.2
6.b.3
6.b.4
Ward Nurse
Physician-in-charge
6.b.5
6.c.1
Ward Nurse
6.c.2
PESU
6.c.3
6.c.4
OPD Nurse/Medical Records

Officer
6.c.5
7.
8.
9.
Presents referral slip from RHU/BHS except for

emergency cases
Enters patients data on referral registry; accomplishes
and gives OPD ID
Makes OPD chart of patient, gets vital signs and chief
complaint, including reason for referral
Refers patient and gives OPD Chart to physician-incharge
Reviews referral slip. Gets patients history, examines,
evaluates and does work-up, diagnose and treats patient
If patient is for medical/pediatric care, gives
prescriptions and instruction to the patient
Fills out return referral slip including clinical summary,
work-ups done, medications and special instructions to
the patient
Gives return referral slip and OPD records to OPD Nurse
Records findings in referral registry
Explains instructions to patient and advises him/her to
give return referral slip to referring health facility
Sends return referral slip to all health facilities bypassed
by the patient
If the patient needs to be confined, accomplishes
admitting history and PE.. findings, Doctors order sheet
and forwards it to the admitting section
Upon discharge, prepares clinical summary to include
special instructions and follow-up needed and
accomplishes return referral slip
Gives it to the Ward Nurse
Explains instructions and gives accomplished return
referral slip and clinical summary
Records patients data in referral registry
If patient is admitted due to notifiable disease, fills out
referral form for epidemiologic surveillance / investigation
and gives it to Ward Nurse
Brings referral form to Provincial Epidemiologic
Surveillance Unit (PESU)
Performs investigation, notifies Physician-in-charge of
results and attaches official report to patients record
Notifies/sends official result of disease investigation
including actions to be undertaken by MHO/RHP
concerned and BHS concerned
Enters patients data in notifiable disease registry
Records and files OPD Chart. Does summary of daily
OPD cases seen
At any stage of the process the Medical Social Worker
may receive referral for social service assistance from the
Hospital staff. Conducts assessment, clarification and
psycho-social interventions as needed
37
37

Tertiary Level / Specialty Hospital (Patient from District/Provincial Hospital
Responsibility
Medical Specialist /
Department Head
Resident
Physician-in-charge
1.
2.
Ward Nurse
3.
4.
5.
6.a
6.b
6.c
7.
8.
Specialty Hospital/Higher 9.
Facility Physician
Patient
10.
Referring hospitals
physician
11.
12.
Action
Evaluates and decides to refer patient
(note: may coordinate with other health
facility for networking)
Prepares detailed and complete clinical
summary, accomplishes referral slip
including reason for referral and gives to
the Ward Nurse
Transcribes in nurses notes and records in
referral registry
If necessary, arranges for ambulance
conduction of the patient
Advises and explains instructions to patient
/ patients companion.
If from the ward, facilitates the discharge of
patient (Refer to Procedure of Issuance of
Clearance)
If from the OPD/ER, advises relatives /
companion to go to the billing section for
payment of used medicines and supplies
(Refer to Billing procedures for patients
from OPD)
Informs medical social worker of referral
Provides services to the psychosocial
needs of the patient and family that has
risen from the impact of the plan to refer
Prepares Social Case Summary and
referral letter
Upon discharge, accomplishes return
referral slip together with the detailed
complete clinical summary including special
instructions
Gives return referral slip / clinical summary
to the referring hospital.
Advises patient regarding follow-up
Sends back referral slip to RHU/BHS
concerned
38
38
INTRA HEALTH FACILITY REFERRAL SYSTEM

Intra-RHU: Programs/Special Projects
Responsibility
MHO/RHP
1.
2.
PHN
3.
4.
5.
Program/Project
Coordinator
6
7.
MHO/RHP
8.
9.
11.
12.
13
14.
15.
Action
Accomplishes inter-program / project
referral slip
Attaches all laboratory results, provisional
diagnosis and actions to be undertaken
Gives it to the Public Health Nurse
Files duplicate referral slip/records in intrareferral registry logbook
Notifies/gives referral to program/project
coordinator concerned
Reviews intra-referral and does
investigation/surveillance and work-up
needed
Records results and makes necessary
recommendations or actions to be
undertaken
Returns back intra-referral slip
Reviews then approves
recommendations/actions to be undertaken
Notifies all concerned
Records and files return referral slip
Carries out orders
Follows-up outcome of actions undertaken
Makes alternative action if necessary
Give feedback results to all concerned
39
39
INTRA HEALTH FACILITY REFERRAL SYSTEM

Intra-Hospital Referral (Inter-Departmental Referral)
Responsibility
Resident Physician-incharge
Senior Resident
Action
1.
2.
3.
Medical Specialist
Ward Nurse
Resident Physician/Senior
Resident
Department to whom the
patient is being refereed to
(Resident physician or
Senior Resident Nurse)
4.
5.
6
7.
8.
9.
10.
11.
Referring departments
physician
Referring Departments
Ward Nurse
12.
13.
13.a
13.b
13.c
13.d
Receiving departments
Ward Nurse
Receiving departments
Resident Physician
Resident Physician incharge
13.e
13.f
13.g
14.
Accomplishes inter-departmental referral slip

Attaches laboratory and other diagnostic results
(i.e., ECG, ultra-sound, x-rays, etc.)
Reviews referral slip and gives provisionary
and differential diagnosis and reason for
referral
Approves referral slip
Records referral in Patients Chart (Nurses notes)
Sends referral slip to the departments physician
to whom the patient is being referred to
Reviews referral slip/history of present illness,
examines patient and evaluates together with
the referring physician
Records findings in the Patients Chart
Makes appropriate suggestions /
recommendations
Seeks approval of suggestion/recommendation
from medical specialist concerned
Returns inter-departmental referral slip to
referring department
Notifies his/her Senior Resident/Medical
Specialist of the results
Carries out suggestions/recommendations and
orders in the patients chart
If patient needs to be transferred to the referred
department, carries out physicians order
Records in patients nurses notes
Notifies Senior Nurse
Transfers patient and does necessary
endorsement of nurses notes
Records patient in list of ward discharges
Receives patient, enters in daily census, carries
out physicians order and notifies resident
physician
Reviews patients records and notifies his/her
senior resident/medical specialist
Records in inter-departmental registry logbook
40
40
Annex B
Sheet 1 Monitoring Form for Incoming Referrals
Date and
time
referred
Name of Patient
Age Sex Complete Impression Referred Reason Method of Return

Address (Given by
From
for
Transport/ Slip
Referring Facility)
Referral Commu- (returned
or not)
nication
Sheet 2 Monitoring Form for Outgoing Referrals

Date and
time
referred
Name of Patient
Age Sex Complete

Medical
Referred Reason Method of Status
Address Impression/
From
for
Transport/ Upon
Diagnosis
Referral Commu- Arrival
nication
Sheet 3
AGE
SEX
M F
0-11 mo
1-4 y.o.
5-14 y.o.
14-59 y.o.
50-64 y.o.
Above 64
MUNICIPALITY/ REFERRED
BARANGAY
FROM
Quarterly Report Form for Incoming Referrals
SPECIFIC REASON FOR REFERRAL
CLASSIFICATION OF CASE
MEDICO PRIORITY FOR OPD OTHERS MED PED OB- SURGERY

GYN
LEGAL ADMISSION (for CASE
hospital only)
Top Ten Leading Referred Cases (for all facilities)

1. _____________________________________
2. _____________________________________
3. _____________________________________
4. _____________________________________
5. _____________________________________
6. _____________________________________
7. _____________________________________
8. _____________________________________
9. _____________________________________
10. ____________________________________
TOTAL NO. OF REFERRED CASES:
No.of Cases
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
REMARKS:
______________________________________________________________________________________________
______________________________________________________________________________________________
Prepared By:
Approved By:
___________________________________
(Signature)
____________________________________
(Signature)
Sheet 4
AGE
SEX
M F
0-11 mo
1-4 y.o.
5-14 y.o.
14-59 y.o.
50-64 y.o.
Above 64
MUNICIPALITY/ REFERRED
BARANGAY
TO
Quarterly Report Form for Outgoing Referrals
SPECIFIC REASON FOR REFERRAL
CLASSIFICATION OF CASE
MEDICO PRIORITY FOR OPD OTHERS MED PED OB- SURGERY

GYN
LEGAL ADMISSION (for CASE
hospital only)
Top Ten Leading Referred Cases (for all facilities)

1. _____________________________________
2. _____________________________________
3. _____________________________________
4. _____________________________________
5. _____________________________________
6. _____________________________________
7. _____________________________________
8. _____________________________________
9. _____________________________________
10. ____________________________________
TOTAL NO. OF REFERRED CASES:
No. of Cases
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
TOTAL NUMBER OF RETURNED SLIPS ________
REMARKS:
______________________________________________________________________________________________
______________________________________________________________________________________________
Prepared By:
Approved By:
___________________________________
(Signature)
____________________________________
(Signature)
___________________________
NAME OF HEALTH FACILITY
________________________
Address
INTRA HEALTH FACILITY REFERRAL SLIP
(RHU / BHS & BHS / RHU)
REFERRED TO:
__________________________
Date: ___________
ADDRESS: ______________________________
PATIENT NAME: ____________________________ Age: ______ yrs. old
ADDRESS: _________________________________ Sex: _______ CS_______
WORKING DIAGNOSIS: ___________________________________________
BRIEF CLINICAL HISTORY AND PHYSICAL EXAM. INCLUDING PAST AND
PRESENT HISTORY
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
MANAGEMENT GIVEN: _____________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
REASON FOR REFERRAL (include service / action to be undertaken):
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
REFERRED BY: __________________________
NOTED BY: ______________________________
47
47
RESULTS OF ACTION UNDERTAKEN (EPIDEMIOLOGIC / SURVEILLANCE)

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
RECOMMENDATION / SUGGESTION (include special instruction and alternative
actions to be taken)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
By: _____________________________
Date: ___________________________
48
48
___________________________
NAME OF HEALTH FACILITY
________________________
Address
INTER HEALTH FACILITY REFERRAL SLIP
REFERRED TO:
__________________________
Date: ___________
ADDRESS: ______________________________
PATIENT NAME: ___________________ Age: _____ Occupation___________
ADDRESS: _________________________________ Sex _______ CS_______
BRIEF CLINICAL HISTORY AND PE (Including past and present history)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
WORKING / PROVISIONAL IMPRESSION: _____________________________
_________________________________________________________________
ACTION UNDERTAKEN (to include medication given, laboratory/diagnostic
procedures, invasive interventions)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
REASON FOR REFERRAL : __________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
REFERRED BY: __________________________
(Attending physician/health worker in-charge)
Noted By: ______________________________
(MHO/COH)
49
49
RETURN SLIP
INTER HEALTH FACILITY REFERRAL SLIP
TO:_____________________________________ Date:____________________
ADDRESS: ___________________________________
FINAL DIAGNOSIS:
_________________________________________________________________
MANAGEMENT including medications, diagnostic procedures, definitive procedures)

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
INSTRUCTIONS/RECOMMENDATIONS (including follow-ups, preventive actions to be

undertaken:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_____________________________
Attending Physician
Noted by: ______________________________

Medical Specialist/COH
50
50
PRO-FORMA DISCHARGE SUMMARY

_________________________
Name of Hospital
_________________________
Address
DISCHARGE SUMMARY
Name of Patient: _________________________
Date: ______________
Address: ____________________________ Age: ____ Sex: ____ C/S:______

Responsible party (if minor): _________________________________________
Relation to patient: _________________________________________________
VITAL SIGNS: BP:______ PR:______ RR:______ WT:______ TEMP:______
Date Admitted: ________________
Date Discharged: __________________
DIAGNOSIS:
_________________________________________________________________
MEDICATIONS GIVEN AND MEDICATIONS TO CONTINUE:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
REMARKS: (include surgical procedure performed / findings, if any, and instructions for followup)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
__________________________________________________
Signature over printed name of Attending Physician
51
51
PRO-FORMA CONSENT SLIP FOR REFERRAL

_________________________
Name of Hospital
_________________________
Address
CONSENT SLIP FOR REFERRAL
Name of Patient: _________________________
Date: ______________
Address: ____________________________ Age: ____ Sex: ____ C/S:______

Responsible party (if minor): _________________________________________
Relation to patient: _________________________________________________
REASON FOR REFERRAL:
___________________________________________________________
___________________________________________________________
___________________________________________________________
CONSENT
(To be translated into the local dialect, if necessary)
I ______________________________________________ consent to be
referred to ___________________ for the reason/s stated above.
______________________________________
Signature over printed name of Patient
Witness: ______________________
52
52
Annex C
Sample Treatment Protocol

TUBERCULOSIS
I. JUSTIFICATION FOR ADMISSION (essential for diagnosis)

1. Presence of pulmonary complications: Chronic Restrictive lung disease with
Cor Pulmonale: Hypoxia: Respiratory Failure
2. Extrapulmonary TB
II. CLINICAL FINDINGS
On and off low grade fever, cough, hemoptysis, signs of extrapulmonary
involvement.
III. TREATMENT AND MANAGEMENT
Sputum AFB smear (3x)
Chest x-ray, SGPT
If(-)
Sputum AFB culture
results pending
If (+)
Treat
2 HRS, 1 HRZES, 5 HRE
Note: For extrapulmonary TB, the diagnostic specimen depends on the

organ that is suspected to be affected
Treatment: 2HRZ 4 HR minimum, maybe extended for one year (ex.
Hepatobiliary TB)
Explanation of Terms:
H-Isoniazid 5-10 mg/kg/d p. o. one dose (up to 400 mg/d)
R-Rifampicin 10 mg/kg/d p. o. one dose (up to 600 mg/d)
Z-Pyrazinamide 25 mg/kg/d p. o. one dose (up to 2.5 g/d)
E-Ethambutol 25 mg/kg/d p. o. OD for 1 month then 15 mg/kg/d
thereafter
S-Streptomycin 25 mg/kg/d p. o.one dose (up to 2.5 g/d)
For extrapulmonary TB: Completion of diagnostic specimen collection or
resolution of life-threatening complications
IV. COMPLICATIONS AND MANAGEMENT
1. Pneumothorax refer to Surgery for CTT insertion
2. Pleural Effusion diagnostic and therapeutic thoracentesis
3. Meningitis
4. Cor Pulmonale
53
V. POSSIBLE REFERRENCE POINTS FOR REFERRAL TO HIGHER LEVEL

FACILITY
1. BHS refers to RHU or first referral hospital when a patient presents with
clinical findings of PTB such as on and off low grade fever, cough, hemoptysis.
2.RHU/first referral hospital refers to core hospital or tertiary provincial hospital
when there are justifications for admission such as presence of pulmonary
complications or extrapulmonary TB.
3. Core hospital or tertiary provincial hospital refers to medical center or regional
hospital in the presence of complications
54
BRONCHIAL ASTHMA
I. JUSTIFICATION FOR ADMISSION (essentials for diagnosis)
1. Acute attack not responsive to conventional therapy (status asthmaticus)
2. With concomitant illness (pneumonia, etc.)
II. CLINICAL FINDINGS
Cough, dyspnea, wheezing, chest discomfort
Laboratories:
peak flow meter 200 liters/min or lower
ABG-usually respiratory alkalosis with hypoxemia
III. TREATMENT AND MANAGEMENT
1. Asthma
Suspect
2. Airway
Obstruction
(by PE)
3. B2 Agonist
(In clinic)
5. PRN B2
4. Definite
Improvement
(within 2 hr)
NO
YES
6.
B2 Agonist
+Oral steroids (High Dose)
x 2 weeks
7. Relief
9. Oral steroids
(High Dose)
x 2 weeks
8. Relief
10. Think again
Asthma Still
Likely?
YES
11. Severe
Chronic
Asthma
12. Other
Disease
13. Relief
NO
14. Asthma
YES
Consider Process
15. Other Disease
55
IV COMPLICATIONS AND MANAGEMENT

1. Acute Respiratory Failure for ventilatory support
2. Pneumothorax-refer to Surgery for CTT insertion
V. POSSIBLE REFERRENCE POINTS FOR REFERRAL TO HIGHER LEVEL
FACILITY
1. BHS refers to RHU or first referral hospital when a patient presents with
difficulty of breathing cough, wheezing, chest discomfort or when known asthmatic
is having another episode
2.RHU/first referral hospital refers to core hospital or tertiary provincial hospital
when symptoms are not relieved after injectable B2 agonist are given.
3. Core hospital or tertiary provincial hospital refers to medical center or regional
hospital in the presence of complications
56
Annex D
Directory of Participants and Resource Persons
Writeshop on the Hospital Referral System Manual
December 12-14 2001
NAME
Dr. Ester Roselle F. Dakiwag
Ms. Melinda G. Gomez
Dr. Romulo B. Gaerlan
Dr. Roland E. Mira
Dr. Regina C. Sobrepena
Dr. Rosalinda Jambaro
Dr. Eduardo P. Cruz
Dr. Esteban Magalona
Ms. Josefina A. Rosales
Dr. Edgardo Sandig
Dr. Condrado M. Brana, Jr.
Dr. Felicito Lozarita
DESIGNATION
MHO
Nurse II
PHO I
MHO
Supervising HPO
Chief of Hospital
MHO
MHO
Chief Nurse III
PHO II
Chief of Hospital
PHO II
OFFICE
MHO, Balbalan, Kalinga
Nueva Valencia Comm. Hospital, Guimaras
Kalinga Provincial Hosp.
Gigaquit RHU, Surigao del Norte
BLHD-DOH
Juan . M. Duyan Dist. Hosp., Kalinga
Taytay, RHU, Palawan
Sibunag, Guimaras
CARAGA Regional Hosp.
IPHO, Koronadal City, South Cotabato
Norala Dist. Hosp., South Cotabato
PHO, San Miguel, Jordan, Guimaras
Dr. Edgar Flores

Dr. Cosnarie E. Seguis
Dr. Washington G. Loreno
Dr. Emmanuel F. Acluba
Ms. Esther Feliciano
Dr. Melecio Dy
Ms. Gabby Doromal
Dr. Andres Galvez
Mr. Dennis Russel D. Baldago
Ms. Mornie L. Mamorno
Ms. Charm I. Nolasco
Ms. Cathrina V. Laurio
OIC, APHO
MSII
MHO
MCH
Devt. Mgt. Officer IV
MS IV
DMO IV-MSS Adviser
Consultant
Project Manager
PDO V
PDO II
PDO II
PHO, Puerto Princesa City

PHO, Surigao del Norte
MHO Tampakan, South Cotabato
Cagayan Valley Medical Center
NCHFD-DOH
NCHFD
NCHFD
ICHSP-DOH
ICHSP-DOH
ICHSP-DOH
ICHSP-DOH
ICHSP-DOH
CONTACT NO
0917-758-3440
0916-303-0653
(074) 872-2366
0919-360-9155
711-6285
0917-383-7263
0919-433-7603
0916-310-0174
0919-223-2355
(083) 228-4117
(083) 238-7611
(033) 581-3331
0919-534-6862
0919-656-8770
0919-583-8809
0919-566-6219
(078) 844-3789
0917-833-2022
781-4332
781-4332
781-5890
743-8301 loc. 60026004
Directory of Participants and Resource Persons

Writeshop on the Hospital Referral System Manual
November 11 and 16 2002
NAME
Dr. Melecio Dy
Ms. Gabby Doromal
Dr. Regina C. Sobrepena
Ms. Leticia Espinosa
Ms. Monalisa Morales
Ms. Emmylou Magbanua
DESIGNATION
MS IV
DMO IV-MSS Adviser
Supervising HPO
CHPO
Project Devlt Officer V
Project Devlt Officer II
OFFICE
NCHFD
NCHFD
BLHD-DOH
BLHD-DOH
ICHSP
ICHSP
CONTACT NO
781-4332
781-4332
711-6285
711-6285
781-5890/4950027
781-5890/4950027
GLOSSARY
1. Level of Care refers to the capability of the health organization to

deliver health care. The levels of care are primary, secondary, and
tertiary and are assigned by the licensing office of the Department
of Health.
2. Stakeholders this refers to the entities or personalities that have an
interest in the health sector
3. Handbook as used in this manual, this is the referral system
manual that has been customized by the stakeholders to their local
setting
4. Referring facility the facility that sends out the patient for
referral, also referred as the sending facility
5. Receiving facility the facility that accepts referred patients.
6. Main Health Center An expanded Rural Health Unit, usually
located in a strategic area where there are no hospitals. It has one or
two lying in beds and may have a larger personnel complement
than a regular RHU.
7. Primary referral hospital the first level hospital within a local
referral network i.e. municipal hospital
8. First referral hospital refers to any level of care hospital assigned
as the initial receiving hospital in the local referral network.
59
References:
Department of Health, Health Sector Reform Agenda, Philippines. 19992004, HSRA Monograph Series No. 2, Manila, December 1999
Roland and Coulter, Hospital Referrals, Oxford University Press, 1992
World Health Organization, The Hospital in Rural and Urban Districts,
Switzerland, 1992
Marilee Karl, Planning, Monitoring and Evaluation of Networking
Dr. E. Sandig, PHO, Health Referral System Manual for the Province of
South Cotabato, South Cotabato, Philippines, 2001
60

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HEALTH REFERRAL

Republic of the Philippines

Local Health Referral System

LIST OF ABBREVIATIONS AND ACRONYMS

THE REFFERAL SYSTEM

OPERATIONALIZING THE HEALTH REFERRAL SYSTEM

THE PATIENT AND HEALTH CARE SERVICES

MONITORING AND EVALUATION

RELEVANT POLICIES AND GUIDELINES

SUMMARY AND CONCLUSION

Specific Tasks at Different Levels of Facility

Local Health Referral System

Intra-Health Facility Referral System

Clinical Records and Referral Slips

Sample Treatment Protocol

Local Health Referral System

Local Health Referral System

Local Health Referral System

Local Health Referral System

List of Abbreviations and Acronyms

Acute Respiratory Infection

Bacillus Calmette Guerrin

Bureau of Food and Drugs

Bureau of Health Facilities and Services

Barangay Health Station

Barangay Health Worker

Blood Smear for Malarial Parasites

Complete Blood Count

Control of Diarrhea Diseases

Clinical Practice Guideline

District Health System

Diptheria Pertussis Tetanus

Expanded Program on Immunization

Local Health Referral System

Health Education and Promotion Officer