9.4.1 Good documentation
During pregnancy, every mother should be advised to get prepared for birth, including what to do if emergency problems occur either in the baby or herself. You should have the standard counselling card from your Region to help you convince the mother and other caregivers to agree to a referral if necessary. In other words, if you tell them she or the baby needs specialist help and treatment from a higher-level health facility, they should be ready to trust your judgement and go.
You should also have a well prepared format to write referral notes to the health facility. You learned how to do this in the Antenatal Care Module, Study Session 13.
What information should a referral note contain?
It should cover the following:
- Date of the referral and time
- Name of the health facility you are sending the patient to
- Name, date of birth, ID number (if known) and address of the patient
- Relevant medical history of the patient
- Your findings from physical examinations and tests
- Your suspected diagnosis
- Any treatment you have given to the patient
- Your reason for referring the patient
- Your name, date and signature
- Your address, so the health facility can communicate back to you.