350 Annex 7.

Decision-making flowchart for

Annex
screen-and-treat
11. Sample documents
strategies

Sample Form 11.3: Sample card that can be used as part of a system to
track patients referred for further diagnostic evaluation
A11
A7
Annex11.
Annex

Cervical screening
7. Sample

Tracking card: Patient referral

Decision-making

Name: ______________
documents flowchart for screen-and-treat strategies

Patient number: ______________ Date of birth:

________________

Home address: ______________

Work address: ______________

Telephone number: ______________

Date screening test done: ______________

Screening test result: ______________

Appointment for referral at: __________________ [name of referral site]

Date of referral appointment: __________________

Tracking record:

Date patient informed of referral appointment: ___________________

Outcome of referral: _______________________________________