Health Referral System Manual PDF

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 v
LIST OF ABBREVIATIONS AND ACRONYMS vi
I. INTRODUCTION 1
II. THE REFFERAL SYSTEM 2

Definition of a Functional Referral System 2
Types of Referrals 3
Framework for Referral System 3
Requisites for a Functional Health Referral System 5
III. OPERATIONALIZING THE HEALTH REFERRAL SYSTEM 8

Steps in Setting-up a Referral System 8
Referral System Flow Chart 10
Referral Procedure 10
IV. THE PATIENT AND HEALTH CARE SERVICES 14

Essential Health Services/Minimum Packages of Activities 14
Categories of Health Providers and Levels of Care 19
Standard Profiles of Health Facilities and Health Personnel 20
V. MONITORING AND EVALUATION 26
VI. RELEVANT POLICIES AND GUIDELINES 28

General Policies 28
Institutional Policy/Guidelines 29
Procedural Guidelines 29
Health Referral Management Activities 30
Support Mechanisms 30
Policies on Medico-legal Cases 31
Importance of Case Management Protocols 32
VII. SUMMARY AND CONCLUSION 33
ANNEXES 34
Annex A Specific Tasks at Different Levels of Facility 35
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
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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 DOH’s 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.
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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.
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List of Figures
Figure no. Title Page
1 Operational Framework: Comprehensive Two-way 6

Referral System
2 Conceptual Framework of the Referral System 7
3 Standard Referral System Flowchart 12
4 Inter-Local Health Zone Referral System 13
v
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
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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 People’s Organization
PS Provincial Sanitaria
RHM Rural Health Midwife

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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
facility’s 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.
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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 patient’s 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 facility’s 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 organization’s 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.
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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 ILHZ’s 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
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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.
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4. Requisites for a Functional Health Referral System:
A well-functioning comprehensive two-way referral system shall have

the following:
1. Defined functions and responsibilities (i.e., service mixes for

each level of care);
2. Identified health service delivery outlets (public and private)
and services provided;
3. Agreed roles and responsibilities of key stakeholders;
4. Agreed standard case management protocols (treatment
protocols and guidelines);
5. Agreed referral policies, protocols, and administrative
guidelines to support the health referral system;
6. System to supervise, monitor, and evaluate quality of care,
referral practices, and support mechanisms;
7. Facilities and health workers capable in implementing the
health referral system; and
8. 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).
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Figure 1 Operational Framework: Comprehensive Two-Way Referral System
PRIMARY
PRIMARY HEALTH
HEALTH CARE
CARE (3RD
(3RD LEVEL
LEVEL
Community
BHS
PRIMARY
HEALTH CARE
( 1st LEVEL )
PRIVATE
RHU HOSPITAL
PRIMARY
HEALTH CARE
(2ND LEVEL)
PRIMARY
HEALTH CARE
MUNICIPAL/
(3RD LEVEL)
DISTRICT
HOSPITAL SECONDARY
HEALTH CARE
PROVINCIAL
HOSPITAL
TERTIARY
HEALTH CARE
(4TH LEVEL)
Legend:
TERTIARY Standard Referral Flow –

MEDICAL/ the usual route of referral
HEALTH CARE
REGIONAL
(5TH LEVEL)
CENTER 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
Legend:
ILHZ
TH - Tertiary Hospital
DH - District Hospital
RHU - Rural Health Unit
BHS - Barangay Health Station
Pvt. Hosp. - 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.
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Planning and Implementation Phase
• 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.
C. 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. Introduction
II. 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. List of health care facilities with corresponding roles;

2. Essential health care services or minimum package of
activities; and
3. List of health personnel.
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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.
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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.
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Figure 3 Standard Referral System Flowchart
Community
BHS
RHU/CHO
Municipal/City/
District/
Private Hospital
Provincial/Private
Hospital
Regional
Hospital
Medical Center
& Specialty
Center
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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

_ Couple’s 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
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_ 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
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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 in–patient care and diagnostic work–up for
possible referral to higher levels of care.
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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
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_ j. Dietician, Nutritionist
_ k. Cook
_ l. Food Service Worker
_ m. Building Maintenance
_ n. House Keeper
_ o. Storekeeper
_ p. Laundry worker
_ q. Utility worker
_ r. 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
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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:
• 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 __________________________________
B. 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 Rural Health Physician / Municipal Health Officer

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

support services. It should at least have the capability to respond to life-
threatening 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 in-
patient 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 hospital–based 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
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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 clinico-
pathological 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
doctor’s orders; prepares patient’s records; assists the physician during
patient examination / treatment, provides information to the patient / family
regarding the patient’s 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.
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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 technician’s 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 MSWO’s

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.
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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. Municipal Health Officer
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.
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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);
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• 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.
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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.
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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
• 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
B. Administrative policies
• 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)
3. 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;
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• 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
patient’s 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.
4. Health Referral Management Activities
A. Orient all stakeholders on the following:
1. Policies
2. Procedures
B. Conduct Quarterly Meetings
1. Assess health referral activities / performance

2. Assess coordinative mechanisms
3. Assess procedures and guidelines
4. 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;
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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 above-

mentioned 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 medico-
legal cases.
7. 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. Justification for admission

b. Diagnostic Criteria
c. Treatment (Management)
d. Complication and Management
e. When to refer
f. Nursing Management
g. Others
VII. 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.
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ANNEXES
34
34
Annex A Specific Tasks at Different Levels of Facility
INTER-HEALTH FACILITY REFERRAL SYSTEM
BHS Level
Responsibility Action
Patient (Old) 1.a Presents ID card from RHM
Patient (New) 1.b Requests for ID card from RHM
RHM 1.b.1 Fills-up client card and issues ID card to
patient
2. Registers patient’s 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
7.b If patient needs confinement, RHM
accompanies patient to the Hospital
(District/Provincial)
35
35
RHU Level (From RHM-RHU Level, Patient within RHU catchment area)
Patient from BHS 1. Presents BHS referral slip
OPD Nurse 2. Reviews referral slip, enters patients’ data
in client registry/logbook and referral
registry
3. Gets vital signs and records findings and
review clinical history
4. Refers patient to MHO
MHO 5. Reviews patient’s records, examines,
evaluates and treats patient
6. If case is simple, discharges patient.
6.a.1 Fills-out return referral slip to include
medications/ instruction to be undertaken
OPD Nurse 6.a.2 Records additional information in referral
registry
MHO 6.b If patient was referred due to notifiable
disease, MHO conducts epidemiologic
surveillance and notifies his/her team to
undertake an examination/investigation
PHN 6.b.1 Enters patient’s data in notifiable diseases
registry and action undertaken
6.b.2 Re-enters additional data when the disease
surveillance has been done
6.b.3 Fills out return referral slip to include
instruction and actions to be undertaken
MHO 6.c. If patient needs further work-up and
confinement, prepares referral slip to
District/Provincial Hospital.
6.c.1 Enters pertinent data, actions undertaken
and reason for referral.
PHN 6.c.2 Records patient’s data in referral registry.
6.c.3 Advises patient to go to hospital and
arranges transport.
6.c.4 May accompany the patient to hospital
concerned, if needed.
6.c.5 Shall accompany emergency cases.
7. If not necessary, advises patient to proceed
to health facility concerned to give return
referral slip
Patient 8. Returns referral slip to RHM
36
36
Hospital Level (patient from BHS/RHU to District / Provincial Hospital)

Patient/Patient’s Companion 1. Presents referral slip from RHU/BHS except for
OPD Nurse emergency cases
2. Enters patient’s data on referral registry; accomplishes
and gives OPD ID
3. Makes OPD chart of patient, gets vital signs and chief
complaint, including reason for referral
OPD Physician-in-charge 4. Refers patient and gives OPD Chart to physician-in-
charge
5. Reviews referral slip. Gets patient’s history, examines,
evaluates and does work-up, diagnose and treats patient
6.a.1 If patient is for medical/pediatric care, gives
prescriptions and instruction to the patient
6.a.2 Fills out return referral slip including clinical summary,
work-ups done, medications and special instructions to
the patient
6.a.3 Gives return referral slip and OPD records to OPD Nurse
OPD Nurse 6.a.4 Records findings in referral registry
6.a.5 Explains instructions to patient and advises him/her to
give return referral slip to referring health facility
6.a.6 Sends return referral slip to all health facilities bypassed
by the patient
OPD Physician-in-charge 6.b1 If the patient needs to be confined, accomplishes
admitting history and PE.. findings, Doctor’s order sheet
and forwards it to the admitting section
Physician-in-charge 6.b.2 Upon discharge, prepares clinical summary to include
special instructions and follow-up needed and
accomplishes return referral slip
6.b.3 Gives it to the Ward Nurse
6.b.4 Explains instructions and gives accomplished return
referral slip and clinical summary
Ward Nurse 6.b.5 Records patient’s data in referral registry
Physician-in-charge 6.c.1 If patient is admitted due to notifiable disease, fills out
referral form for epidemiologic surveillance / investigation
and gives it to Ward Nurse
Ward Nurse 6.c.2 Brings referral form to Provincial Epidemiologic
Surveillance Unit (PESU)
PESU 6.c.3 Performs investigation, notifies Physician-in-charge of
results and attaches official report to patient’s record
6.c.4 Notifies/sends official result of disease investigation
including actions to be undertaken by MHO/RHP
concerned and BHS concerned
6.c.5 Enters patient’s data in notifiable disease registry
OPD Nurse/Medical Records 7. Records and files OPD Chart. Does summary of daily
Officer 8. OPD cases seen
Medical Social Worker 9. 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
Medical Specialist / 1. Evaluates and decides to refer patient
Department Head (note: may coordinate with other health
Resident facility for networking)
Physician-in-charge 2. Prepares detailed and complete clinical
summary, accomplishes referral slip
Ward Nurse including reason for referral and gives to
the Ward Nurse
3. Transcribes in nurse’s notes and records in
referral registry
4. If necessary, arranges for ambulance
conduction of the patient
5. Advises and explains instructions to patient
/ patient’s companion.
6.a If from the ward, facilitates the discharge of
patient (Refer to Procedure of Issuance of
Clearance)
6.b 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)
6.c Informs medical social worker of referral
Medical Social Worker 7. Provides services to the psychosocial
needs of the patient and family that has
risen from the impact of the plan to refer
8. Prepares Social Case Summary and
referral letter
Specialty Hospital/Higher 9. Upon discharge, accomplishes return
Facility Physician referral slip together with the detailed
complete clinical summary including special
instructions
Patient 10. Gives return referral slip / clinical summary
to the referring hospital.
Referring hospital’s 11. Advises patient regarding follow-up
physician 12. Sends back referral slip to RHU/BHS
concerned
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38
INTRA HEALTH FACILITY REFERRAL SYSTEM
Intra-RHU: Programs/Special Projects
MHO/RHP 1. Accomplishes inter-program / project
referral slip
2. Attaches all laboratory results, provisional
diagnosis and actions to be undertaken
3. Gives it to the Public Health Nurse
PHN 4. Files duplicate referral slip/records in intra-
referral registry logbook
5. Notifies/gives referral to program/project
coordinator concerned
Program/Project 6 Reviews intra-referral and does
Coordinator investigation/surveillance and work-up
needed
7. Records results and makes necessary
recommendations or actions to be
undertaken
8. Returns back intra-referral slip
MHO/RHP 9. Reviews then approves
recommendations/actions to be undertaken
Notifies all concerned
11. Records and files return referral slip
12. Carries out orders
13 Follows-up outcome of actions undertaken
14. Makes alternative action if necessary
15. Give feedback results to all concerned
39
39
INTRA HEALTH FACILITY REFERRAL SYSTEM
Intra-Hospital Referral (Inter-Departmental Referral)
Resident Physician-in- 1. Accomplishes inter-departmental referral slip
charge 2. Attaches laboratory and other diagnostic results
Senior Resident (i.e., ECG, ultra-sound, x-rays, etc.)
3. Reviews referral slip and gives provisionary
and differential diagnosis and reason for
referral
Medical Specialist 4. Approves referral slip
Ward Nurse 5. Records referral in Patient’s Chart (Nurses’ notes)
Resident Physician/Senior 6 Sends referral slip to the department’s physician
Resident to whom the patient is being referred to
Department to whom the 7. Reviews referral slip/history of present illness,
patient is being refereed to examines patient and evaluates together with
(Resident physician or the referring physician
Senior Resident Nurse) 8. Records findings in the Patient’s Chart
9. Makes appropriate suggestions /
recommendations
10. Seeks approval of suggestion/recommendation
from medical specialist concerned
11. Returns inter-departmental referral slip to
referring department
Referring department’s 12. Notifies his/her Senior Resident/Medical
physician Specialist of the results
Referring Department’s 13. Carries out suggestions/recommendations and
Ward Nurse orders in the patient’s chart
13.a If patient needs to be transferred to the referred
department, carries out physician’s order
13.b Records in patient’s nurses notes
13.c Notifies Senior Nurse
13.d Transfers patient and does necessary
endorsement of nurses’ notes
13.e Records patient in list of ward discharges
Receiving department’s 13.f Receives patient, enters in daily census, carries
Ward Nurse out physician’s order and notifies resident
physician
Receiving department’s Reviews patient’s records and notifies his/her
13.g
Resident Physician senior resident/medical specialist
Resident Physician in- Records in inter-departmental registry logbook
charge 14.
40
40
Annex B
Sheet 1 Monitoring Form for Incoming Referrals
Date and Name of Patient Age Sex Complete Impression Referred Reason Method of Return
time Address (Given by From for Transport/ Slip
Referring Facility)
referred Referral Commu- (returned
or not)
nication
Sheet 2 Monitoring Form for Outgoing Referrals

Date and Name of Patient Age Sex Complete Medical Referred Reason Method of Status
time Address Impression/ From for Transport/ Upon
referred Diagnosis Referral Commu- Arrival
nication
Sheet 3 Quarterly Report Form for Incoming Referrals
MUNICIPALITY/ REFERRED
AGE SEX BARANGAY SPECIFIC REASON FOR REFERRAL CLASSIFICATION OF CASE
FROM
M F MEDICO PRIORITY FOR OPD OTHERS MED PED OB- SURGERY

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

LEGAL ADMISSION (for CASE GYN
hospital only)
0-11 mo
1-4 y.o.
5-14 y.o.
14-59 y.o.
50-64 y.o.
Above 64
Top Ten Leading Referred Cases (for all facilities) No. of Cases
1. _____________________________________ __________
2. _____________________________________ __________
3. _____________________________________ __________
4. _____________________________________ __________
5. _____________________________________ __________
6. _____________________________________ __________
7. _____________________________________ __________
8. _____________________________________ __________
9. _____________________________________ __________
10. ____________________________________ __________
TOTAL NO. OF REFERRED 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: _____________________________
Municipal Health Officer
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 follow-
up)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
__________________________________________________
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(-) If (+)
Sputum AFB culture Treat

results pending 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 3. B2 Agonist 4. Definite YES

Obstruction (In clinic) Improvement
(by PE) (within 2 hr)
NO
5. PRN B2 6. B2 Agonist
+Oral steroids (High Dose)
x 2 weeks
7. Relief
9. Oral steroids 8. Relief

(High Dose) YES
x 2 weeks 10. Think again 11. Severe
Asthma Still Chronic
Likely? Asthma
12. Other
Disease
13. Relief 14. Asthma
NO 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 DESIGNATION OFFICE CONTACT NO
Dr. Ester Roselle F. Dakiwag MHO MHO, Balbalan, Kalinga 0917-758-3440
Ms. Melinda G. Gomez Nurse II Nueva Valencia Comm. Hospital, Guimaras 0916-303-0653
Dr. Romulo B. Gaerlan PHO I Kalinga Provincial Hosp. (074) 872-2366
Dr. Roland E. Mira MHO Gigaquit RHU, Surigao del Norte 0919-360-9155
Dr. Regina C. Sobrepena Supervising HPO BLHD-DOH 711-6285
Dr. Rosalinda Jambaro Chief of Hospital Juan . M. Duyan Dist. Hosp., Kalinga 0917-383-7263
Dr. Eduardo P. Cruz MHO Taytay, RHU, Palawan 0919-433-7603
Dr. Esteban Magalona MHO Sibunag, Guimaras 0916-310-0174
Ms. Josefina A. Rosales Chief Nurse III CARAGA Regional Hosp. 0919-223-2355
Dr. Edgardo Sandig PHO II IPHO, Koronadal City, South Cotabato (083) 228-4117
Dr. Condrado M. Brana, Jr. Chief of Hospital Norala Dist. Hosp., South Cotabato (083) 238-7611
Dr. Felicito Lozarita PHO II PHO, San Miguel, Jordan, Guimaras (033) 581-3331
0919-534-6862
Dr. Edgar Flores OIC, APHO PHO, Puerto Princesa City 0919-656-8770
Dr. Cosnarie E. Seguis MSII PHO, Surigao del Norte 0919-583-8809
Dr. Washington G. Loreno MHO MHO Tampakan, South Cotabato 0919-566-6219
Dr. Emmanuel F. Acluba MCH Cagayan Valley Medical Center (078) 844-3789
Ms. Esther Feliciano Devt. Mgt. Officer IV NCHFD-DOH 0917-833-2022
Dr. Melecio Dy MS IV NCHFD 781-4332
Ms. Gabby Doromal DMO IV-MSS Adviser NCHFD 781-4332
Dr. Andres Galvez Consultant ICHSP-DOH
Mr. Dennis Russel D. Baldago Project Manager ICHSP-DOH 781-5890
Ms. Mornie L. Mamorno PDO V ICHSP-DOH 743-8301 loc. 6002-
Ms. Charm I. Nolasco PDO II ICHSP-DOH 6004
Ms. Cathrina V. Laurio PDO II ICHSP-DOH
Directory of Participants and Resource Persons

Writeshop on the Hospital Referral System Manual
November 11 and 16 2002
NAME DESIGNATION OFFICE CONTACT NO
Dr. Melecio Dy MS IV NCHFD 781-4332
Ms. Gabby Doromal DMO IV-MSS Adviser NCHFD 781-4332
Dr. Regina C. Sobrepena Supervising HPO BLHD-DOH 711-6285
Ms. Leticia Espinosa CHPO BLHD-DOH 711-6285
Ms. Monalisa Morales Project Devl’t Officer V ICHSP 781-5890/4950027
Ms. Emmylou Magbanua Project Devl’t Officer II ICHSP 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. 1999-

2004”, 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

II. THE REFFERAL SYSTEM 2

III. OPERATIONALIZING THE HEALTH REFERRAL SYSTEM 8

IV. THE PATIENT AND HEALTH CARE SERVICES 14

V. MONITORING AND EVALUATION 26

VI. RELEVANT POLICIES AND GUIDELINES 28

VII. SUMMARY AND CONCLUSION 33

Annex A Specific Tasks at Different Levels of Facility 35

Inter-Health Facility Referral System

Intra-Health Facility Referral System

Annex B Clinical Records and Referral Slips

Monitoring Form for Incoming Referrals

Annex C Sample Treatment Protocol 53

Annex D Directory of Participants 57

This Manual was developed to serve as a guide in setting-up the referral

This document, developed in collaboration with specialists, experts, and

The Project Management Team extends its appreciation to the participants

The development of this Manual was made possible through the

Recognition and appreciation is also extended to the following NCHFD

Dr. Robert S. Enriquez, Division Chief

Figure no. Title Page

1 Operational Framework: Comprehensive Two-way 6

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

EPI Expanded Program on Immunization

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

MSW Medical Social Worker

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

RHM Rural Health Midwife

RHP Rural Health Physician

RHU Rural Health Unit

RSI Rural Sanitation Inspector