CLINICAL SERVCIE PRACTIVE MANUAL
POLICY STATEMENT
Referral
Purpose: Provision of service must be co-ordinated across the full spectrum of care. The following policy sets out
the minimum requirements for the management of referrals received by or made to other service
providers as well as initiated internally between SCDHB services.
Scope:
All employees of SCDHB
Alert:
Referrals to more than one service
A separate ERMS referral shall be made for each service required.
If a patient has been referred to more than one service, and a consultant of one service is made aware
of a change in the patient's health status that would be reasonably expected to be of concern to another
service, then they shall inform the second service of the change, either verbally or in writing, and a note
made of the discussion or written referral in the patient record.
If a patient has been referred to more than one service, correspondence sent by any one service to the
GP shall be copied to every other service.
Policy Statement:
All referrals for primary, community, secondary, tertiary or diagnostic services for South Canterbury
District Health Board patients are to be made to the SCDHB.
External referrals are written to the service required not to an individual clinician.
All referrals requesting radiological investigations are to be managed as per the policy for Referring for
Medical Imaging.
Referrals received by SCDHB
Referrals will only be accepted if they meet the documented entry criteria for the service.
All referrals including First Specialist Appointment (FSA) for secondary and community services must
be managed through the relevant entry point to the service. Where patients have had an FSA in the
private sector and there is a recommendation for a surgical procedure, this must be sent to the Inpatient
Booking Office to be prioritised in the same way as all elective bookings.
Departments providing community/secondary care services e.g. Emergency Department, Clinical Nurse
Specialists, Therapy Services, Dietetics, Audiology and AT&R, Mental Health, Social Work and District
Nursing must have in place a documented:
entry criteria for the service
process for receiving, recording and acknowledging referrals to referrer and patient, including the
indicative waiting time.
process for assessing referral for completeness and contacting referrer if information is missing
approved tool for prioritising referrals
clear process for who prioritises
process for scheduling appointments
process for responding to patients who self-refer
FILE NUMBER: CSPM R28
AUTHOR: CNM Out Patient/ OAO Coordinator
AUTHORISED: Sep 2020
REVIEW DUE: Sep 2022
This is a controlled document. The electronic version is the most up-to-date. Printed versions are valid on the day of printing only.
Page 1 of 3
CLINICAL SERVCIE PRACTIVE MANUAL
POLICY STATEMENT
process for those patients declined entry to the service with recommendations for alternative
options
timeframes for referral management
process for patients who fail to attend (including advice to the referrer)
auditing of referral management e.g. timeliness of referral processing
Referrals made within SCDHB services
It is a requirement that patients are told when a request for an opinion has been made to a service
including the name of the health professional that the referral has been made to. Where a transfer of
care is agreed, the patient/family/whanau must be informed. Where the patient is unable to provide
consent this must be sought from family/whanau or EPOA/guardian (see Informed Consent Policy
CSPM I2).
All referrals should clearly communicate any need for urgent review.
It is courteous to ensure that all appropriate records, investigations and x-rays are available for the
consultation.
A consultant to consultant referral for an FSA will be prioritised as for all primary and secondary referrals
based on clinical need. Where it is the considered clinical opinion that an FSA appointment is not
required then the consultant prioritising the referral will contact the referring consultant and discuss a
treatment plan.
Verbal referrals for inpatients can be made at Multidisciplinary Team (MDT) meetings, by phone or
informal discussion by a health professional provided the referrer documents an entry in the patient’s
clinical record indicating a verbal referral has been made. For inpatient psychiatric referrals there is a
referral form.
Verbal referrals for community patients must be recorded on the appropriate referral form by the clinician
receiving the referral and processed through the relevant entry point to service.
The health professional receiving the verbal referral must document the date and outcome of the
consultation in the patient’s clinical record.
Discussions between services may occur without the patient being physically assessed. It is good
practice to make a written note of the conversation in the patient’s clinical record.
Written referral for inpatients must be made using the appropriate referral form for the service requested.
Non urgent medical referrals to other secondary services within the DHB should be made in writing and
sent to the Outpatient Appointment Office for processing.
Written referrals for community patients may be made via electronic communication or written referral.
These will be processed in accordance with prioritisation tool.
Referrals made to other service providers including other DHBs
Urgent referral to another service provider should be made by the patient’s lead clinician and would
normally include a telephone call to both the receiving clinician as well as to the service the patient is
being transferred to on acceptance. A written referral must accompany the patient on transfer with a
copy filed in the patient’s clinical file. Refer to transfer/transport policy in the Clinical Services Practice
Manual. The patient/family/whanau must be informed.
Non urgent referral to another service provider should be made in writing and sent directly to the service
provider with a copy of the referral filed in the patient’s clinical file.
FILE NUMBER: CSPM R28
AUTHOR: CNM Out Patient/ OAO Coordinator
AUTHORISED: Sep 2020
REVIEW DUE: Sep 2022
This is a controlled document. The electronic version is the most up-to-date. Printed versions are valid on the day of printing only.
Page 2 of 3
CLINICAL SERVCIE PRACTIVE MANUAL
POLICY STATEMENT
Definitions:
FSA – First Specialist Assessment
Process:
For referrals within SCDHB the date and time for the following is required to be documented in the
clinical record or on the referral form
referral complete
referral received
acceptance of referral
first initial face to face or phone contact with patient
copy of the non-acceptance letter if referral declined or documented entry in progress notes
pertaining to contact with referrer informing them of the non-acceptance to service and reasons for
this.
For written referrals within SCDHB services all sections of the referral form must be filled in marking any
sections that do not apply as ‘not applicable’ (N/A) – they should not be left blank. An entry in the clinical
record is documented stating that the referral has been made. Referrals can either be faxed or sent by
internal mail. Where the referral is faxed the original is placed in the patient’s clinical record and if
written a photocopy placed in the clinical record. If the referral has not been acknowledged within 24
hours, then this must be followed up e.g. by phone as a reminder with an entry made in the clinical
record.
The health professional receiving the referral must document the date and outcome of the consultation
in the patient’s clinical record either in the progress notes or by completing the appropriate section of
the referral form. The original referral form must then be filed in the patient’s clinical record.
Subsequent to referral to another service, it is ideal for the consultant who gives an opinion to continue
to be consulted if ongoing care or advice is required whilst the patient remains in hospital. Where follow
up is required within the outpatient clinic ideally it should be with the same person who was consulted
when the patient was an inpatient.
Associated Documents:
DNA Protocol for Hospital Stay Patients
CSPM D1
Service Frameworks
J:\General\Service Framework
Transfer/Transport: Patient
CSPM T3
Consultant to Consultant Referral
CSPM
Senior Medical Staff Handover
CSPM
Referring for Medical Imaging
CSPM
FILE NUMBER: CSPM R28
AUTHOR: CNM Out Patient/ OAO Coordinator
AUTHORISED: Sep 2020
REVIEW DUE: Sep 2022
This is a controlled document. The electronic version is the most up-to-date. Printed versions are valid on the day of printing only.
Page 3 of 3
