inter agency patient referral report

How do I fill out an inter-agency referral form?

Fill out the inter-agency referral form in triplicate (x1 copy with referring agency, x1 copy with client/ caregiver, x1 copy to receiving agency). Provide the referral agency’s contact information to the client and accompany them to the referral agency if needed.

What is inter-agency referral form and guidance note 9 Annex 2?

Inter-Agency Referral Form and Guidance Note 9 Annex 2: Description of key terms in the referral form Section on the referral form Explanation and examples4 Location Examples include the name of a specific camp, or a physical street address. The client/ care giver should be able to physically locate the receiving agency from this information.

What is the purpose of a referral form?

The referral form is intended to be used by humanitarian organisations working with persons with MHPSS problems. The referral form and guidance note are tools to facilitate inter-agency referrals, referral pathways, trainings and workshops, and as a means to document referrals in accordance with minimum standards.

Where can I make a referral to?

A referral can be made to a variety of services, for example health, psychosocial activities, protection services, nutrition, education, shelter, material or financial assistance, physical rehabilitation, community centre and/ or a social service agency. Who can use the referral form?

How to implement an inter agency referral system?

The successful implementation of an inter-agency referral system includes participating agencies to (1) endorse uniform referral documentation (e.g., a uniform referral form - see IASC referral forms and key in Annex 1 and Annex 2), (2) agree on specific referral pathways, procedures and standards for making referrals (e.g., which organisation will be best suited to serve which kind of clients), (3) train relevant staff on the use of documentation, standards and procedures, and (4) participate in coordination activities such as a 4Ws MHPSS service mapping (Who is doing What, Where and When), coordination meetings and referral workshops. These steps should be coordinated through existing mechanisms, such as inter-agency MHPSS coordination groups or through relevant clusters/ working groups. It is recommended that this effort is cross-sectoral, including actors from sectors such as nutrition, camp coordination and camp management, education, protection, MHPSS, and health.

What is a referral form?

The referral form is intended to be used by humanitarian organisations working with persons with MHPSS problems. The referral form and guidance note are tools to facilitate inter-agency referrals, referral pathways, trainings and workshops, and as a means to document referrals in accordance with minimum standards. The referral form and guide can be used by any service provider for example, by a Doctor working in a primary healthcare centre referring a child to a child friendly space or a nutrition feeding programme, or a Case Manager referring a client for physical rehabilitation. It can also be used by persons providing Psychological First Aid, depending on the person’s role/ responsibilities, after a distressing event. The referral form is designed to facilitate referrals between and within all four levels of the IASC MHPSS Intervention pyramid1. Case Managers and Community Workers may find the tool of particular use in their work with individual clients and their families. The referral form is not a tool to detect persons with mental, neurological and/ or substance use (MNS) disorders, rather it can be used to refer persons to mental health care services for assessment and further management.

How are referrals disaggregated?

referrals (made & received) disaggregated by service, gender and age. Level of satisfaction of people with MHPSS problems regarding the referral/ or referral process # of clients (out of the total number of clients) who were successfully referred to other services. # and % of referrals received from other service providers. Increase in staff and volunteers’ knowledge and capacity to make successful referrals Referral documentation forms Inter-Agency quality and tracking measurements Weekly/ monthly activity reports Client satisfaction survey Feedback forms/ surveys Client files Referral documentation forms Monthly/ quarterly activity reports (take a baseline, mid and end-line to measure changes over time) Staff/ volunteer competency checklist Pre and delayed post tests Supervision sessions

What is referral in healthcare?

A referral is the process of directing a client to another service provider because s/he requires help that is beyond the expertise or scope of work of the current service provider. A referral can be made to a variety of services, for example health, psychosocial activities, protection services, nutrition, education, shelter, material or financial assistance, physical rehabilitation, community centre and/ or a social service agency.

What is the purpose of a referral?

I, (client name), understand that the purpose of the referral and of disclosing this information to (receiving agency) is to ensure the safety and continuity of care among service providers seeking to serve the client. The service provider, (referring agency), has clearly explained the procedure of the referral to me and has listed the exact information that is to be disclosed. By signing this form, I authorize this exchange of information. Signature of Responsible Party: (Client or Caregiver if a minor). Date (DD/MM/YY):

What is family tracing services?

Family Tracing Services Restoring family links; reunification services; best interest assessment (BIA) and alternative care for unaccompanied and separated children. Legal Assistance Access to legal advice including through paralegals and lawyers; housing, land and property issues; and documentation (e.g., identification cards and certificates for: birth, death, marriage, divorce and educational qualifications etc.). Nutrition Mother-baby groups, promotion of breastfeeding practices, therapeutic-feeding for severe and/ or acute malnutrition and cognitive stimulation groups. Any contact or other restrictions (Y/N) This question relates to the protection of the client being referred and the principle of ‘Do No Harm’. In some cases, (such as persons with mental health disorders, survivors of sexual and gender based violence, or in cases of child protection), there may be certain restrictions on how to contact the client and how to provide services/ support to ensure that you are not causing additional harm. This is important in protection-related cases when the perpetrator maybe a family or a community member, and when working with persons with mental health problems to minimise any related stigma and to ensure confidentiality. In such situations, the client may request that she/ he be contacted through a close friend, another relative or a trusted community member, or through another medium such as via e-mail, rather than through the telephone. Please write any such concerns or restrictions in the space provided on the form. Information agencies agree to exchange in follow up In functioning referral systems, there is often a need for an exchange of information between the referring agency and the receiving agency. In most situations this is just a confirmation receipt for a referral, but in other situations additional information exchange maybe required, whilst respecting the client’s wishes for confidentiality (e.g., if one agency is providing case management services and is responsible for coordinating a client’s referrals).

Can you email referrals by phone?

Any contact or other restrictions? Yes No (If yes, explain below) Referral delivered via: Phone (emer gency only) E-mail Electronically (e.g., App or database) In Person Follow-up expected via: Phone E-mail In Person. By date (DD/MM/YY): Information agencies agree to exchange in follow up: Name and signature of recipient: Date received (DD/MM/YY):