Concept of Operations: Relating to the introduction of a Personally Controlled Electronic Health Record System
4.3.5 ReferralsThe PCEHR System will support collection of Referrals. When a healthcare provider creates a Referral, it will be sent directly to the intended recipient, as per current practices, and a copy of the Referral may also be sent to the PCEHR System.
The PCEHR System will accept Referrals as either level 1, 2 or 3 clinical document.
Structured Referrals will be conformant with the forthcoming Australian Standards, which are based on the NEHTA Referral specifications [NEHTA2010f].
In addition to the common fields, a Referral may contain:
- Benefits card details (optional)
- Patient's nominated contact (optional)
- Referrer (required)
- Usual GP (optional)
- Referee (required)
- Referral details (required)
- Current and past medical history (required)
- Current medications (required)
- Allergies/adverse reactions (required)
- Diagnostic investigations (optional)
- Attachments (optional)
|Scope Notes: Note that current NEHTA referral specifications only support GP to Specialist Referrals. Other forms of Referral will be supported via level 1 clinical documents in the first release.|
|eHealth Site Notes: All wave 1 sites and a number of wave 2 sites will be informing the creation and management of referrals.|