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Data Element Detail

Outpatient clinic written referral
Identifying and Definitional Attributes
QH 040927 v2
Data Element
Data Element Concept
Draft
19-May-2011		Current
25-Jun-2011		Retired
30-Jun-2015
Standard
01-Jul-2010
30-Jun-2015
A written request to an outpatient clinic for investigation and/or diagnosis, advice on or provision of treatment/management, and/or reassurance and second opinion for a patient.
Hospital outpatient clinic services excluding community mental health care (which includes hospital-based mental health ambulatory services).
Representational Attributes
Permissible Values

Permissible_values

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Supplementary Values

Supplemenary_values

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Collection and Usage Attributes
WRITTEN REFERRAL CONTENT
The referring practitioner must identify the patient's need for referral and communicate relevant information about the patient to the medical officer or designated authority.

All referrals to an outpatient clinic must be in writing (e.g. letter, facsimile, electronic file, noted in patient's medical record) and contain the following:
- Patient demographic information and contact details;
- Referring practitioner contact details;
- Relevant information about the patient's condition and the need for specialist services;
- Signature of referring practitioner; and
- Referral issue date.

The following information is also required if available or known at the time of referral:
- Investigations and treatment undertaken;
- Past medical and surgical history;
- Current medications;
- Patient status; and
- Relevant psycho-social issues.

ACTIVE LIFE OF A WRITTEN REFERRAL *
A referral for a specialist outpatient service will remain valid for a single course of treatment, or for a period of twelve months from the initial outpatient clinic service, whichever is the lesser.

On the occasion of referral for a chronic or long-term condition that will extend beyond twelve months, a written indication from the referring practitioner (within the referral) is requisite detailing that the patient has a clinical condition that will require continuing care and management by a specialist consultant physician. Examples of such conditions could include but are not limited to the specialties of Renal and Oncology. In these instances wording on the referral must indicate that the referral is either valid for an indefinite period or for a period greater than 12 months.

* It should be noted that the 12-month period specified as the 'active life of a referral' for a specialist outpatient service is based on a standard General Practice referral to a specialist or a consultant physician. These conditions do not apply in the main to referrals required for the purpose of billing the Health Insurance Commission for private 'Medicare funded' patients. Eg: Where a referral originates from a specialist or a consultant physician, the referral is valid for 3 months.
Relational Attributes
Related Metadata References

Related Metadata References_IR

  • 1 - 3
ViewRelationshipMetadata Item TypeMetadata Item SubtypeNameIdentifier & VersionApproval Status
SupersedesData ElementData Element ConceptNon-admitted patient care-specialist outpatient service-referralQH 040927 Version 1Superseded
Relates toData ElementData ElementOutpatient clinic service request-receipt dateQH 040929 Version 2Superseded
Relates toData ElementData ElementOutpatient clinic written referral-issue dateQH 040928 Version 2Superseded
Implementation in Metadata Sets

Implemented

No Metadata Items
Source and Reference Attributes
Queensland Health
Outpatient Services Implementation Standard
Outpatient clinic; Referral;