Category: All Templates

Podiatry Template

Scott McLaughlin

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

Which service is this referral aimed at:

  • General Podiatry
  • MSK Podiatry
  • Diabetes
  • Nail Surgery

Is this a request for a domicilliary visit:

  • Yes
  • No

Main Presenting Complaint: [Text – 98 character maximum]

Reason for Referral: [Text]

Date of Onset: [Date]

Priority:

  • Routine
  • Urgent

Priority Reason: [Text – 98 character maximum]

Podiatry Guideline

Urology Cancer Template

Scott McLaughlin

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]

World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:

Options:

  • Asymptomatic
  • Symptomatic but completely ambulatory
  • Symptomatic, <50% in bed during the day
  • Symptomatic, >50% in bed, but not bedbound
  • Bedbound

Priority: Urgent Suspicion of Cancer

Date of Onset: [Date]

Prefered Hospital:

  • Hairmyres Hospital
  • Monklands Hospital
  • Wishaw General Hospital
  • First Available appointment

Clinical Examinations and Findings

Examinations and Findings

Frank haematuria in an adult (unexplained):

  • Yes (If Yes, please provide brief details)
  • No

Symptomatic, non-visible haematuria in a patient over 40 years old:

  • Yes (If Yes, please provide brief details)
  • No

Palpable renal mass with/without pain, with/without haematuria:

  • Yes (If Yes, please provide brief details)
  • No

Solid renal mass found on imaging:

  • Yes (If Yes, please provide brief details)
  • No

PSA outwith age related reference range:

  • Yes (If Yes, please provide brief details)
  • No

Clinically malignant prostate on PR exam and/or bone pain suspicious of metatastic prostate cancer:

  • Yes (If Yes, please provide brief details)
  • No

Swelling in body of testis or other suspicion of testis cancer:

  • Yes (If Yes, please provide brief details)
  • No

Suspected penile cancer:

  • Yes (If Yes, please provide brief details)
  • No

Investigations

Please indicate if any of these tests have been checked.

MSSU:

  • Yes
  • No

U&E and FBC:

  • Yes
  • No

PSA – after patient has been counselled:

  • Yes
  • No

Urology cancer guideline

Skin Cancer Template

Scott McLaughlin

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]

World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:

Options:

  • Asymptomatic
  • Symptomatic but completely ambulatory
  • Symptomatic, <50% in bed during the day
  • Symptomatic, >50% in bed, but not bedbound
  • Bedbound

Priority: Urgent Suspicion of Cancer

Expected Outcome:

  • Not specified
  • Diagnostic advice

Date of Onset: [Date]

Will the patient accept any site for treatment:

  • Yes
  • No

Lesions and Risks

Lesion Characteristics

Duration of lesion (months): [Text]

Site of lesion: [Text]

Size of lesion (mm): [Text]

Are there any changes to the lesion?

  • Yes
  • No

Lesion Specific Details

If Yes to the above question, Are there any changes to the lesion?, please answer the following:

Change in leasion size:

  • Yes
  • No

Is there irregular pigmentation:

  • Yes
  • No

Are there irregular borders:

  • Yes
  • No

Is the lesion inflamed:

  • Yes
  • No

Does the lesion itch or have altered sensation:

  • Yes
  • No

Is the lesion larger than others:

  • Yes
  • No

Does the lesion bleed or ooze:

  • Yes
  • No

Risk Factors

Has the patient had previous sunbed exposure:

  • Yes
  • No

Is the patient immunosuppressed:

  • Yes
  • No

Does the patient have a history of skin cancer:

  • Yes
  • No

Has the patient had a previous transplant:

  • Yes
  • No

Provisional Diagnosis

Provisional diagnosis:

  • Other
  • Melanoma
  • Basal cell carcinoma
  • Squamous cell carcinoma
  • Cutaneous lymphoma

Other (please specify): [Text]

Skin cancer guidelines

 

Orthodontics Template

Scott McLaughlin

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

 

Ophthalmology Cataract Template (Optom use only)

Scott McLaughlin

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.

Optometry Referral Details

Date of Referral: [Date]

Priority: [Routine]

Patient history and details: [Text]

Patient symptomatic:

  • Yes
  • No

Cataract Information

Lifestyle affected:

  • Yes
  • No

Wants Surgery:

  • Yes
  • No

Cataract leaflet given:

  • Yes
  • No

AMD present:

  • Yes
  • No
  • Don’t know

Ocular examination – External/Internal

Comment right eye: [Text]

Comment left eye: [Text]

Tonometry (value between 0-50mmHg)

Applanation:

  • Yes
  • No
  • Not possible

Right: [Text]

Left: [Text]

Relative afferenct pupilary defect:

  • Yes
  • No

Fields affected: 

  • Yes
  • No

Last eye test

Date of test: [Date]

Right acuity:

  • 6/4.5
  • 6/5
  • 6/6
  • 6/9
  • 6/12
  • 6/18
  • 6/24
  • 6/36
  • 6/60
  • 3/60
  • 1/60
  • CF
  • HM
  • P of L
  • No P of L

Left acuity:

  • 6/4.5
  • 6/5
  • 6/6
  • 6/9
  • 6/12
  • 6/18
  • 6/24
  • 6/36
  • 6/60
  • 3/60
  • 1/60
  • CF
  • HM
  • P of L
  • No P of L

Refraction Details

Right Vision

R Sph: +/-

R Cyl: +/-

R Sph: [Between 0 – 25]

R Cyl: [Between 0 – 15]

R Axis: [Between 0 – 180]

R VA:

  • 6/4.5
  • 6/5
  • 6/6
  • 6/9
  • 6/12
  • 6/18
  • 6/24
  • 6/36
  • 6/60
  • 3/60
  • 1/60
  • CF
  • HM
  • P of L
  • No P of L

R PH VA:

  • 6/4.5
  • 6/5
  • 6/6
  • 6/9
  • 6/12
  • 6/18
  • 6/24
  • 6/36
  • 6/60

R Add: [Between 1 – 4]

R NVA:

  • N4.5
  • N5
  • N6
  • N8
  • N9
  • N10
  • N12
  • N14
  • N18
  • N24
  • N36
  • N48
  • NIL

Left Vision

L Sph: +/-

L Cyl: +/-

L Sph: [Between 0 – 25]

L Cyl: [Between 0 – 15]

L Axis: [Between 0 – 180]

L VA:

  • 6/4.5
  • 6/5
  • 6/6
  • 6/9
  • 6/12
  • 6/18
  • 6/24
  • 6/36
  • 6/60
  • 3/60
  • 1/60
  • CF
  • HM
  • P of L
  • No P of L

L PH VA:

  • 6/4.5
  • 6/5
  • 6/6
  • 6/9
  • 6/12
  • 6/18
  • 6/24
  • 6/36
  • 6/60

L Add: [Between 1 – 4]

L NVA:

  • N4.5
  • N5
  • N6
  • N8
  • N9
  • N10
  • N12
  • N14
  • N18
  • N24
  • N36
  • N48
  • NIL

Ophthalmology Cataract Guideline

 

Lung Cancer Template

Scott McLaughlin

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]

World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:

Options:

  • Asymptomatic
  • Symptomatic but completely ambulatory
  • Symptomatic, <50% in bed during the day
  • Symptomatic, >50% in bed, but not bedbound
  • Bedbound

What does the patient know: [Text]

Results

Chest X-ray:

  • Normal
  • Abnormal – Suspicion of cancer
  • Abnormal – other

Date of chest x-ray: [Date]

Blood sample for e-GFR taken within past 3 months: 

  • Yes
  • No

Priority: Urgent Suspicion of Cancer

Date of Onset: [Date]

Will the patient accept any site for treatment:

  • Yes
  • No

Lung cancer referral guideline

Haematological Cancer Template

Scott McLaughlin

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]

World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:

Options:

  • Asymptomatic
  • Symptomatic but completely ambulatory
  • Symptomatic, <50% in bed during the day
  • Symptomatic, >50% in bed, but not bedbound
  • Bedbound

Priority: Urgent Suspicion of Cancer

Date of Onset: [Date]

Will the patient accept any site for treatment:

  • Yes
  • No

Symptoms and Investigations

Symptoms

History – Please add more details where required.

Fatigue:

  • Yes (If Yes, please provide brief details)
  • No

Night Sweats:

  • Yes (If Yes, please provide brief details)
  • No

Weight Loss:

  • Yes (If Yes, please provide brief details)
  • No

Itching:

  • Yes (If Yes, please provide brief details)
  • No

Breathlessness:

  • Yes (If Yes, please provide brief details)
  • No

Bruising:

  • Yes (If Yes, please provide brief details)
  • No

Recurrent Infections:

  • Yes (If Yes, please provide brief details)
  • No

Bone Pain:

  • Yes (If Yes, please provide brief details)
  • No

Polyuria and polydipsia (with normal glucose)

  • Yes (If Yes, please provide brief details)
  • No

Clinical Examinations

Hepatomegaly:

  • Yes (If Yes, please provide brief details)
  • No

Splenomegaly:

  • Yes (If Yes, please provide brief details)
  • No

Lymphadenopathy greater than 2cm over 6 weeks:

  • Yes (If Yes, please provide brief details)
  • No

Haematology cancer guideline