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  • Hnru Referral Form

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    agn4201
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    HNRU REFERRAL FORM (11)

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    11 views2 pages

    Hnru Referral Form

    Uploaded by

    agn4201

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 2

    QUEZON PWHS FORM NO.

    REFERRAL FORM
    REFERRAL CATEGORY
     EMERGENT  URGENT  NON-URGENT
    PROVINCIAL HEALTH OFFICE REASON FOR REFERRAL
    QMC Compound, Barangay 11, Lucena City  TRANSFER OF SERVICE  DIAGNOSTIC
    E-mail: [email protected]
    Contact Number: 09209228787 FB: Quezon HNRU  OUTPATIENT CONSULTATION  STEP DOWN CARE
     SPECIFIC SERVICE:
    _______________________________
    Referring Facility
    NAME OF HEALTH FACILITY
    Rizal Street, Poblacion, Atimonan Quezon | 042-754-4582 | 0908-149-3556 | [email protected]

    REFERRED TO DATE (MM/DD/YYYY) / /

    ADDRESS TIME

    AGE SEX CIVIL STATUS


    PATIENT NAME
    F M
    ADDRESS CONTACT NO.
    BIRTHDATE (MM/DD/YYYY) / / RELIGION
    PHILHEALTH NUMBER/ DETAILS

    CHIEF DIAGNOSIS / CLINICAL IMPRESSION


    COMPLAINT
    RELEVANT CLINICAL HISTORY

    PERTINENT PHYSICAL / DIAGNOSTIC FINDINGS

    VITAL CLINICAL STATUS


    BP: / mmHg O2SAT: %

    HR: bpm TEMP: O


    C

    RR: cpm WEIGHT: kg

    GCS SCORE: _________ (E_____/V_____/M_____)

     WITH ATTACHED CLINICAL RECORD  WITHOUT ATTACHMENT REFER TO TREATMENT COURSE SUMMARY AT THE BACK, IF APPLICABLE

    REFERRING HEALTH RECEIVING FACILITY


    PROVIDER
    NAME & SIGN CONTACT
    DESIGNATION PERSON
    CONTACT NO. DESIGNATION
    REFERRAL FACILITATED BY QHNRU? YES
    NO

    PLEASE RETURN THIS PORTION TO THE REFERRING FACILITY QUEZON PWHS FORM NO. 4a
    NAME OF REFERRING FACILITY REFERRAL FORM
    ADDRESS OF REFERRING FACILITY RETURN SLIP
    PHONE NUMBER / EMAIL

    DATE (MM/DD/YYYY) / / TIME

    PATIENT NAME AGE SEX F M

    DIAGNOSIS/
    IMPRESSION

    ADMITTED UNDER OBSERVATION MANAGED & DISCHARGED


    ACTION TAKEN/
    DISCHARGED FOR FOLLOW-UP  REFERRED TO OTHER FACILITY
    OUTCOME
    OTHER:
    SIGNATURE ABOVE RECEIVING
    PRINTED NAME OF FACILITY
    ATTENDING CONTACT
    PROVIDER NUMBER
    PATIENT COURSE
    AGE SEX
    PATIENT NAME F M

    DATE ADMITTED (MM/DD/YYYY) / / ADMITTED AT  ER  WARD  OTHER:


    DIAGNOSIS /
    IMPRESSION

    DATE/TIME TREATMENT GIVEN / PERTINENT DIAGNOSTIC RESULTS

    CONTENTS OF THIS DOCUMENT MAY FORM PART OF THE PATIENT’S PERSONAL HEALTH/ MEDICAL DATA
    AND MAY BE PROTECTED UNDER THE DATA PRIVACY ACT.

    CLIENT SATISFACTION SURVEY


    Bilugan ang numero na angkop sa inyong kasagutan tungkol sa iyong naging karanasan.
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    karanasan sa proseso ng referral.

    Nakatanggap ako ng agarang


    HINDI SUMASANG-AYON ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 ) SUMASANG-AYON
    serbisyo.

    Magalang at marespeto ang mga


    HINDI SUMASANG-AYON ( 1 ) ( 2 ) ( 3 ) ( 4 ) ( 5 ) SUMASANG-AYON
    nagbibigay ng serbisyo.
    Komento o suhestiyon.

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