Age-friendly Primary Health Care Centres Toolkit - World Health ...

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AGE-FRIENDLY PRIMARY HEALTH CARE CENTRES TOOLKITIII.5 Referral system between the PHC centre and the hospitalThe following information should be included in all referrals to other hospitals, specialistsor other health care providers• From: Referring doctor name____________• To:__________________• Date:________________• Re:__________________• Medical diagnoses: _____________• Present Medications: __________• Reason for referral:• Signature: _________.The following form is an example of the reply from the provider to whom you referClinic nameClinic addressClinic phone and email contactTo: Doctor concernedDate:Patient’s labelThe above-mentioned is under the care of XXX clinic that provides community-basedprimary geriatric care, in collaboration with aged-care agencies in the community.Your update on the outcome of today’s visit is invaluable to us in the care of this olderperson.Please feel free to speak to me if you need any information on this patient for yourclinical management.Yours sincerelySPECIALIST’S REPLY (PLEASE COMPLETE AND RETURN TO THE PATIENT ONTHE SAME DAY AS THE VISIT)92
AGE-FRIENDLY PRIMARY HEALTH CARE CENTRES TOOLKITName:Identification number:------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------________________ _____________ ___________________Signature of Doctor Name of Doctor Clinic’s StampSource: Form provided by the TSAO Foundation, Singapore93
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Age-friendly Primary Health Care Centres Toolkit - World Health ...

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