VICTORIAN STATEWIDE REFERRAL FORMS
A Guide to Using the Electronic Service Coordination Tools Template in Medical Director
This resource prepared by Dandenong District Division of General Practice and the South East Primary Care Partnership with funding from the Victorian Department of Human Services
Victorian Statewide Referral Forms
Since 2000, the Victorian Government has developed the Primary Care Partnerships Strategy (PCP). PCPs involve a range of primary care and community based service providers with the aim of improving the way services work together.
Victorian Statewide Referral Forms
What does this mean? Through the PCP initiative efforts are being made to streamline and coordinate referral processes. Importantly, and increasingly, agencies are now able to use common processes for collecting and sharing patient/client information using standardised referral documentation.
Victorian Statewide Referral Forms
Is this a good thing? The main benefits for patients include: • reduction in unnecessary repetition and duplication of patient information; • capacity for improved referral to a broad range of health and allied services.
Victorian Statewide Referral Forms
How will it benefit General Practice?
• there is just one referral form for a range of key agencies and services;
• improved communication and feedback with other services;
Victorian Statewide Referral Forms
To assist GPs using this referral process the forms are now combined as a single template in Medical Director.
This includes three key components:
The Cover Sheet (similar to a fax cover),
the Consumer Information form (personal and demographic details),
and the Summary & Referral Information form (details of reason for referring, services required, etc).
Victorian Statewide Referral Forms
This Guide will show you how to use the forms in Medical Director. Simply follow the steps described
(NB. You can follow these instructions and work in Medical Director at the same time. Press Alt+Tab to alternate between windows)
Note: The Victorian Statewide Referral Form included in Medical Director as a Supplied Template is part of a suite of forms developed through the Primary Care Partnership Service Coordination program. The suite in its entirety is generally referred to as the Service Coordination Tools Template.
Victorian Statewide Referral Forms
For the purpose of this exercise it is assumed that you have some familiarity with Medical Director.
In particular, you need to be familiar with the Letter Writer function.
• To open and use the Victorian Statewide Referral Forms:
1. Open the patient record 2. Open Letter Writer (go to „Tools‟ on the menu bar and select „Letter Writer‟ from the drop down box).
Victorian Statewide Referral Forms
The Statewide Referral Form is available as a “Supplied” template*. To use the form open a new document (File > New) Click the Supplied tab, scroll down and highlight Victorian Statewide Referral Form. Click OK.
* NB. If the template is not under „Supplied‟, check „User Defined‟.
Victorian Statewide Referral Forms
The Template enables you to select specific information from patient files in Medical Director to add to the referral. This includes:
Select Addressee Progress Notes Selection Investigation Selection User Defined Fields
The amount of information added to the template depends on what is recorded elsewhere in your files. You can edit this information later if necessary.
Victorian Statewide Referral Forms
To Select Addressee
The Addressee is the individual or service provider you are referring your patient to. This information comes from your Medical Director Address Book
Select the Addressee from the list and click OK. This information will be added to the referral form.
(Note: Check your Medical Director Users Guide for adding new entries to the Address Book)
Victorian Statewide Referral Forms
To Add Progress Notes
Relevant events to be included in the referral may be selected from the Progress Notes. To select required information click the checkbox or double click the date.
Victorian Statewide Referral Forms
Adding Progress Notes (continued)
To review notes of selected visits, click on the date to highlight then click the View button. Click the Close button when you have finished.
When you select dates, all details of that visit will be included in the referral form. This information may be edited when all other elements of the referral are completed. When all required Progress Notes have been selected, click the OK button. If you do not wish to add any Progress Notes, click the Cancel button on the dialogue window.
Victorian Statewide Referral Forms
• Adding Investigations
The Template will ask you to add Investigations next. This follows the same process as Adding Progress Notes.
Victorian Statewide Referral Forms
Additional Information Required
Some information required for the referral will not be automatically included. The final dialogue box in the templates asks you to manually add some information that is not in the Patient Record.
Victorian Statewide Referral Forms
Additional Information (cont.)
Review Date This is the date that the GP intends to review the patient following referral. This is provided to the Agency/Service Provider for information. If you wish to enter a date click on the check box then click the down arrow. Choose a date from the calendar.
The default is the current day, but if the box is not checked (the date is in grey text) that date will not appear in the referral.
Victorian Statewide Referral Forms
Additional Information (cont.)
Consumer Privacy Information Provided? Under new State and Federal privacy laws it is a requirement to ensure that referred patients are aware of and agree to the exchange of confidential information. The Patient Consent Form and Consumer Privacy Information brochure are provided as an additional template in Medical Director. These can be printed as required or, if it is more convenient, multiple copies can be pre-printed and kept as hard copy.
Click the check box to indicate that this information has been obtained.
Victorian Statewide Referral Forms
Additional Information (cont.)
Does the patient require an interpreter? This will default to “1 – Interpreter not needed”. If required, click the down arrow (drop-down list) to select the second option “2 – Interpreter needed” If the second option is selected, type in the language required in the next field box.
Victorian Statewide Referral Forms
Additional Information (cont.)
Reason for patient referral: This text box allows you to describe the reason for the referral and add any other relevant information. This is a multi-line text box that allows you to type as much information as you wish.
This entry will appear twice in the referral form – firstly under the heading “Why the consumer is seeking services” and again in the “Initial Action Plan” section. You are able to edit or summarise this information in the final document before you print or send the referral.
Victorian Statewide Referral Forms
Additional Information (cont.)
Patient consent to referral and information sharing: The drop-down list provides you with three options regarding patient consent: 1. 2. 3. Yes, patient consents to referral and sharing of information Yes, patient consents to referral but not sharing of information No, patient has not consented to this referral
The first option is the default setting, based on the assumption that this will generally be the case following discussion with the patient.
Victorian Statewide Referral Forms
Additional Information (cont.)
Referral method: The drop-down list provides you with five options regarding the method of referral:
1. This form faxed to agency
2. Letter (copy on file) 3. Electronic 4. Verbal request, face to face or phone call
5. Other (incl. refer to self)
The first option is the default. In future, electronic transfer will be more readily available.
Victorian Statewide Referral Forms
Additional Information (cont.)
Referral feedback requested: The drop-down list provides you with five options regarding where the Agency should send feedback (ie. receipt of referral and future correspondence): 1. To initial referral agency 2. To the GP (Default setting) 3. To agency completing INI (initial needs identification) 4. To carer/guardian 5. Other
These options relate to the range of service providers using the Service Coordination Tools Template. For a GP generated referral it should be assumed that feedback will be sent to the GP.
Victorian Statewide Referral Forms
Additional Information (cont.)
When this additional information is complete click the OK button.
This will produce the completed document, which may now be edited as required.
Victorian Statewide Referral Forms
• Editing the final referral form
1. Cover Sheet
The cover sheet is similar to a fax cover sheet. It automatically contains practice contact details, details of service referred to and an overview of the referral. COMMENTS Section: You may add any specific information that is required, such as alerts, comments on additional risks, urgency and access issues.
Victorian Statewide Referral Forms
• Editing the final referral form (cont.)
NB. Agencies have agreed to the following protocol: Referral acknowledgement and feedback on the status of the referral (eg. Client to be assessed on date, client placed on waiting list, client not eligible for services) is provided within two days if marked High Priority, within three days if marked Routine.
If the referral is marked Urgent, then the referrer (i.e. GP) should follow up with a telephone call Feedback on the outcome of the referral (that is, what services have been provided and patient outcomes) is provided after the initial assessment by the service provider, if the client consents. If the assessment is not to be done within 1 week of receiving the referral or if anything changes (eg. Improvement, decline, termination) the GP is to be notified.
Victorian Statewide Referral Forms
• Editing the final referral form (cont.)
IMPORTANT!
In Medical Director ALL information you have in the patient record regarding warnings, allergies, social history, current medications and past medical history will be automatically added to this form in the Notes section.
It is important that the GP review this section and delete any information that is not appropriate or relevant to the particular referral.
Victorian Statewide Referral Forms
The final page of the form should be completed during the editing stage, particularly if the GP is involved in a multidisciplinary care plan. 1. Current Services
Insert details of services relevant to this referral, including name of services and contact information (practitioner name, telephone number, address)
2.
Initial Action Plan
This table is completed earlier. You may wish to insert or edit the information previously entered in the “For” column.
Victorian Statewide Referral Forms
• Saving and Printing the Form
Save an electronic version of the form in the patient‟s file by selecting File > Save Print a hard copy for mailing or faxing by selecting File > Print Note: some of the shaded areas in the form may not fax clearly if sent directly from the computer. If faxing the referral, print a hard copy first.
Victorian Statewide Referral Forms
Patient Consent Form & Privacy Brochure
The Patient Consent Form and Privacy Brochure are included in Medical Director as Supplied Templates in Letter Writer. • To open, follow the same steps as for opening other Templates: Letter Writer > Supplied > Patient Consent Form • Select the addressee (i.e. the same addressee as selected when you completed the Referral template). • • Save the form and print it out. Tick relevant boxes as appropriate. Patient and GP sign copy. The Consumer Privacy Brochure should be given to the patient.
Victorian Statewide Referral Forms
These forms will be used more and more throughout the primary health sector. It is important that General Practitioners are familiar with the referral process and can complete them with relative ease. It is hoped that these electronic versions will assist GPs to initiate appropriate and informative referrals.
Thank you.
ATTACH – PRINT-FRIENDLY VERSIONS OF THE FORMS AND LINKS TO MEDICAL DIRECTOR TEMPLATES (at DDDGP website?)