Referral of patient from primary to secondary care

Purpose: 

Requesting of specialist care, including the transferral of relevant medical information

Relevance: 

For the referral of a patient, all relevant medical information should be accessible by the healthcare professional who will be responsible for further treatment. 

Domain: 
Referral and Discharge Reporting
Scale(s): 
National/Regional
Context: 

The electronic referral of a patient from a GP to a specialist often consists of a referral letter, containing the reason for referral, some information on the complaints and findings, and additional information such as medical history and current medication. Often, there is no electronic sending of this letter: it s given to the patient, who brings it with him if he or she visits the specialist. A workflow where the entire referral process can be tracked and managed would create a more efficient process, and a better transfer of medical information (i.e., electronic and structured data). This Use Case describes such an improved workflow. 

Information: 
Referral letter
Patient Summary
Participants: 
Patient
HCP in primary care (GP)
HCP in secondary care (specialist)
Functional process flow: 
  1. Patient visits his GP. The GP decides to refer the patient to a specialist
  2. The patient signs a patient consent
  3. The GP generates a referral letter through his Primary Care Information System that automatically selects data from the system, and creates a patient summary. It also generates a template of a referral letter. The GP adds the reason for referral, and other relevant information that is not in the automatically generated patient summary.
  4. The GP opens a web-based program, logs in, and selects a specialist.
  5. The GP sends the referral to the specialist via a secure connection
Source: