Table 3.

Form contents and their mapping.

Ebonyi State Ministry of Health referral slip	National Health Insurance Scheme (NHIS) referral form	Women, infants, and children referral form for pregnant women
Facility name	Facility name NHIS code	N/Aa
N/A	Date	Measurement date
Patient number and social insurance number	Health Management Organization (HMO) NHIS ID number HMO code	—
Name of patient	Name	Patient's name (last, first)
Age	Date of birth	Date of birth (MM/DD/YY)
Sex	Sex	—
Address	N/A	Address (state, city, zip code)
N/A	N/A	Telephone number
Complaints	Presenting complaint	—
Findings on examination	Examination findings	Height, weight Hemoglobin (g/dL), hematocrit (%), and blood test date
Investigations performed, if any	Investigation results	—
Provisional diagnosis	Provisional diagnosis	—
N/A	Reason for referral post medical history taking Clinical warnings (allergies)	Estimated date of confinement Date when last pregnancy ended Gravida Para Pregravida weight (lbs) Indicate any of the following medical conditions (diabetes, multiple pregnancies, hypertension, tuberculosis, previous poor pregnancy outcome, and history (specify) If other, current history of the condition (specify)
Current and recent medication	N/A	Current medication and supplements prescribed
N/A	Other relevant information	Impressions and comments
Name of officer	Referring doctor Medical and Dental Council of Nigeria number Receiving doctor’s Medical and Dental Council of Nigeria number Date	Name of the physician care provider group and clinic
Designation	N/A	—
Signature	Signature and stamp	Health care provider Signature Date
To	Health facility NHIS code	—

^aN/A: not applicable.