Category: General Practice Templates
General Practice referral dictation templates
Orthodontics Template
This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.
Why do you feel the patient needs hospital based orthodontic management?
- Orthodontic / Minor oral surgery
- Orthodontic / Restorative
- Orthodontic / Orthognathic (jaw) surgery
- Cleft lip / palate
- Orthodontic / paediatric dentistry management
- Special needs patient
- Second opinion
Reason for Referral: [Text]
Priority: [Routine]
Date of Onset: [Date]
Has the patient previously attended the department to which they are being referred?
- Yes
- No
- Don’t know
Has the patient previously attended any NHS Lanarkshire hospitals for treatment?
- Yes
- No
- Don’t know
Please provide details of previous admissions or attendances: [Text]
Does the patient have any special requirements, e.g. disability, autism, etc.:
- Yes
- No
Please provide details of special requirements: [Text]
Orthodontics Referral Guideline
Oral Maxillofacial Surgery Template
This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.
Presenting Complaint
Main presenting complaint:
- Other lump / swelling
- Other oral mucosal lesions
- Oral / facial pain
- Salivary gland problems
- Temporo-mandibular joint problems
- Oro-facial disproportion / deformity
- Requiring minor oral surgery
Based upon the answer to the question above, please select the appropriate option from the questions below.
If ‘Oral/Facial pain’ is selected, no further information is required here.
If ‘Temporo-mandibular joint problems’ is selected, no further information is required here.
If ‘Other lump/swelling’:
- Oral
- Facial
- Neck
If ‘Other oral mucosal lesions’:
- Long-term mucosal pigmented lesion
- Other mucosal abnormality
- Mucosal bullous lesion
- ROAU
If ‘Salivary gland problems’:
- Major gland
- Minor gland
- Salivary calculus
- Dry mouth
If ‘Oro-facial disproportion / deformity’:
- Skeletal growth abnormalities
- Cleft lip palate
- Post traumatic abnormalities
If ‘Requiring minor oral surgery’:
- Third molar/impacted tooth
- Other tooth/root
- Peri-radicular
- Pre-prosthetic
- Pre orthodontic
Reason for Referral: [Text]
Priority:
- Routine
- Urgent
- Urgent – Suspicion of cancer
Date of Onset: [Date]
Priority Reason: [Text – 98 character maximum]
General Referral Template
This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.
Presenting Complaint
Main Presenting Complaint: [Text – 98 character maximum]
Reason for Referral: [Text]
Date of Onset: [Date]
Priority:
- Routine
- Urgent
Priority Reason: [Text – 98 character maximum]
Advice Only Request Template
This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.
Presenting Complaint
Main Presenting Complaint: [Text – 98 character maximum]
Reason for advice request: [Text]
Date of Onset: [Date]
Priority: [Advice Only]
If the patient has previously been seen by, or a letter has been sent to, this specialty, please provide details including date (where possible).
Patient last seen by this specailty: [Text]
Addictions Dictation Template
This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.
With this referral there is a possibility that information will be shared with Social Work Misuse Services and other agencies.
Is the client aware that information may be shared?
- Yes
- No
Other Agencies Involved
District nursing team involved:
- Yes
- No
Social Work involved:
- Yes
- No
Child protection involved:
- Yes
- No
Adult Supervision/Protection involved:
- Yes
- No
Additional Related Risk Assessment
Any current suicide risk:
- Yes
- No
If the patient has high suicide risk please give further details and actions taken: [Text]
Any history of aggression or violence or any risk to visiting staff:
- Yes
- No
If Yes, please provide details: [Text]
Any relevant physical disability or mental health problems:
- Yes
- No
Please detail or check that the details are presnet in the past medical history: [Text]
Please select all that apply:
- Responsible for children
- Domestic abuse
- Homeless or risk of
- Currently injecting
- Sharing injection equipment
- Self harm or injury
- Recent custodial sentence
- Pregnancy
- If pregnant please provide the due date: [Date]
Presenting Complaint
Main Presenting Complaint:
- Alcohol
- Drugs
- Alcohol and drugs
- Other
If alcohol referral please detail type, amount, how often, how long and anu features of dependency: [Text]
FAST score if known: [Text]
For drugs referral please detail substance, amount, how often and how long: [Text]
Current medication related to addiction. Please detail if not shown in medication record: [Text]
Date of Onset: [Date]
Priority:
- Routine
- Urgent
The service would consider pregnancy, sole carer of children and adults under Adult Support and Protection Act to be urgent.
If you consider the case to be ‘Urgent’ please give details: [Text]
Acne Referral Template
This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.
Presenting Complaint
Main Presenting Complaint: [Text – 98 character maximum]
Reason for Referral: [Text]
Date of Onset: [Date]
Priority:
- Routine
- Urgent
Priority Reason: [Text – 98 character maximum]
Acne Severity:
- Mild
- Moderate
- Severe nudulocystic