HCPN

Name of HEALTH CARE PROVIDER NETWORK

LOGO MNHCN – RPRH REFERRAL FORM

To:___________________________________ Date/Time referred:___________________________

REFERRAL CATEGORY: ( ) A1 ( ) A2 ( ) B1 ( ) B2 ( ) C1 ( ) C2 ( ) Unclassified

Name of Referring Facility: Tel/CP No. E-mail Add.

Address of Referring Facility: Messenger Acct.

Patient’s Name: Age: Sex: Civil Status: Date of Birth:

Address: Tel/CP No. Contact Person:

Blood Type: OB Score: LMP: ___________ With Pre-natal Where? (Clinic Name/Address):
G___ P ____ EDD: ___________ ( ) Yes ( ) No
(________) AOG:___________ No. of PNCU: ______
Vital Signs: Fundic Height Fetal Heart Internal Examination (IE):
BP : ___________ HR : ___________ (FH): Tone (FHT):
RR :___________ Temp: ___________
Weight: _____________
Danger Signs:
( ) Unconscious (Does Not Answer) ( ) Convulsing ( ) Looks Very Ill ( ) Others, _________
( ) Pre-Term Labor ( ) Severe Difficulty of Breathing ( ) Headache
( ) Vaginal Bleeding ( ) Fever ( ) Severe Visual Disturbance
( ) Severe Abdominal Pain ( ) Severe Vomiting ( ) Prom
Medical History:

Laboratory Work-Up and Results: (Attach results if Available)

Medication Dosage Date/Time Given Medication Dosage Date/Time Given

( ) Methergin ( ) MsSO4
( ) Oxytocin ( ) Hydralazine
( ) Dexamethasone ( ) Others
IMPRESSION: REASON FOR REFERRAL:
( ) Consultation ( ) Transfer of Service
( ) Diagnostic Test ( ) Others _________
RPRH REFERRAL If Yes, method of choice Counseled: ( ) Yes ( ) No
( ) Yes ( ) No ( ) IUD ( ) PSI ( ) Pills ( ) Condom ( ) Consent (Name & Signature of Client):
BTL _____________________________
( ) Vasectomy ( ) Injectable ( ) SDM ( ) LAM
NEWBORN REFERRAL: Name of newborn: Sex: Accompanying relative:
( ) Yes ( ) No
Date and Time of birth: Manner of delivery: Presentation:

Weight: ___________kgs. APGAR Score: 1st min _______ 5th min ________ ( ) Preterm ( ) Term ( ) Post Term
Anthropometric Measurement: Routine newborn care: Vital Signs: BP ________mmHg
HC ________ cms AC _______ cms ______ Vit K ______ BCG CR ______bpm TEMP : ________ ͦ C
CC ________ cms BL _______ cms ______ HEP – B VAC RR ______bpm O2 Sat : ________%
______ ERYTHROMYCIN ______NBS
Condition at birth: Impression:
_____ meconium stained _____ poor cry/activity _____ convulsion CBG ________mg/dl
_____ poor suck _____ jaundice _____ cyanosis Congenital anomalies:
_____ respiratory distress (DOB) _____ bleeding _____ cord coil _________________
Others: (pls. specify) ___________________________________
Diagnostics: Management: (to include IVF, O2 support,
medications)

Mode of Transportation: Name and designation of accompanying personnel:

( ) ambulance ( ) aircraft ( ) others _____________
( ) private car ( ) boat
History of Previous Confinement: ( ) No ( ) Yes
If Yes, Diagnosis ________ Month and Year of Confinement: ______________________
Printed Name and Designation of REFERRING Personnel: Telephone/CP No.

Printed name and designation of RECEIVING facility personnel who accepted the Telephone/CP No.
referral call:
 RETURN SLIP
Name of Referring Facility:
_______________________________________________________________________
Address of Referring Facility:
_______________________________________________________________________

Name of Receiving facility: Date and time received: Tel/ CP No.

Patient’s Name: Age: Sex: C/S

PATIENT DISPOSITION:
( ) Admitted ( ) observation ( ) Referred to another facility specify _____________________
( ) return back to referring facility ( ) managed and discharged ( ) Others _____________________
Printed Name and Signature of Receiving/Attending Physician Telephone/CP No.

BACK – REFERRAL FORM

Name: Age: Sex:

Name of Newborn: Date of Birth:

Address: Contact Number:

Final Diagnosis:

Date of Admission: Date of Discharge:

Discharge Medication and Home Instructions

Follow – up Check -up on: Name of Facility:

*Please bring with you the Back – Referral Form during your follow-up check