Assessment of formats and completeness of paper-based referral letters among urban hospitals in Rwanda: A retrospective baseline study

Research output: Working paperPreprint


Background: Patient referral is a process in which a healthcare provider decides to seek assistance at a higher level of care. Paper-based referrals predominantly used in low-income countries hardly follow any procedures. This causes a major gap in communication, coordination, and continuity of care between primary and specialized levels, leading to poor access, delay, duplication and unnecessary costs. The goal of this study is to assess the formats and completeness of existing
paper-based referral letters to improve health information exchange, coordination, and continuity of care for the hospitals in the urban environment of Kigali.
Methods: A retrospective exploratory research was conducted in eight public and three private healthcare facilities in the city of Kigali from July 2019 to July 2021. A purposive sampling method was used to select referral letters from patients’ files. A data capture sheet was designed according to the contents of the referral letters and were analyzed descriptively.
Results: In public hospitals, there were five updated referral letters in total agreement with world health organization (WHO) standards of which two (neonatal transfer form and patient monitoring transfer form) were not used. There was also one old format that was used by most hospitals and another format designed and used by a district hospital (DH) separately. Three formats were designed and used by private hospitals (PH) individually. A total of 2,304 referral letters were
perused and the results show that “external transfer” forms were completed at 58,8%; “antenatal, delivery, and postnatal external transfer” forms at 47,5%; “internal transfer” forms at 46,6%; “Fiche de référence / Contre reference” forms at 46,0%; district hospital (DH2) at 73,4%. Referrals by private hospitals (PH1, PH2 and PH3) were completed at 97,7%, 70,7%, and 0.0% respectively.
Conclusions: There were inconsistencies in the format of the available referral letters used by public hospitals though some of them were incompatible with WHO standards. Additionally, there were deficits in the completeness of referral letters. There is a need to disseminate the national patient referral guideline in public hospitals with emphasis on referral feedback, referral registry, triage, archiving, and regular training organization.
Original languageEnglish
Publication statusSubmitted - 5 Apr 2022


  • Patient referral
  • referral letters
  • referral completeness

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