Liaison Service Report

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Basic Information

Department *

Month *

Year *

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Referral-Ins

1. Total number of referral-ins

Breakdown by urgency

Emergency Referral

Non-Emergency Referral

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Referral-Outs

2. Number of people referred to other health facility

Breakdown by urgency

Emergency Referral

Non-Emergency Referral

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Admissions, Discharges & Waiting List

3. Total Number of patients in waiting list for elective surgery

4. Total Number of admissions

5. Total number of discharges

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Top 10 Reasons for Referral Out

Enter the top reasons for referring patients to other health facilities this month. Short answers are sufficient.

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