Category: All Templates

Gynaecology, Suspicion of 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

Persistant intermenstrual bleeding:

  • Yes
  • No

Persistent postcoital bleeding:

  • Yes
  • No

Postmenopausal bleeding (not on HRT):

  • Yes
  • No

Postmenopausal bleeding on combined continuous HRT or unscheduled bleeding on sequential HRT:

  • Yes
  • No

Persistent abdominal pain:

  • Yes
  • No

Abdominal distension:

  • Yes
  • No

Clinical Examination

Abdominal /  Pelvic mass palpable by abdominal examination:

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

Ascites

  • Yes
  • No

Cervical or vaginal lesion, suspicion of cancer:

  • Yes
  • No

Vulval lesion suspicion of cancer:

  • Yes
  • No

Investigation

Please indicate if any of the following have been checked

FBC and ESR sent:

  • Yes
  • No

CEA sent (if ovarian cancer suspected):

  • Yes
  • No

CA125 sent (if ovarian cancer suspected):

  • Yes
  • No

Ultrasound scan arranged:

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

Gynaecology, Suspicion of Cancer Guideline

 

 

General Referral 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]

Date of Onset: [Date]

Priority:

  • Routine
  • Urgent

Priority Reason: [Text – 98 character maximum]

Gastrointestinal (Upper) Cancer, Surgeon 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

Unexplained weight loss:

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

Unexplained iron deficiency anemia:

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

Family history of oesophago-gastric cancer in more than two first degree relatives:

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

Family history of familial adenomatous polyposis in any first degree relative:

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

Barrett’s oesophagus:

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

Pernicious anaemia:

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

Gastric surgery over 20 years ago:

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

Known dysplasia, atrophic gastritis, intestinal metaplasia:

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

Upper abdominal epigastric mass:

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

Iron deficiency anaemias:

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

Clincal Examination

Jaundice:

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

Upper abdominal mass:

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

Investigations

FBC and ESR sent:

  • Yes
  • No

LFT, U&E sent:

  • Yes
  • No

Previous endoscopy done:

  • Yes
  • No

Upper GI cancer surgeon guideline

Gastrointestinal (Upper) Cancer, Endoscopy 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

Unexplained weight loss:

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

Unexplained iron deficiency anemia:

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

Family history of oesophago-gastric cancer in more than two first degree relatives:

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

Family history of familial adenomatous polyposis in any first degree relative:

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

Barrett’s oesophagus:

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

Pernicious anaemia:

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

Gastric surgery over 20 years ago:

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

Known dysplasia, atrophic gastritis, intestinal metaplasia:

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

Upper abdominal epigastric mass:

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

Iron deficiency anaemias:

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

Clincal Examination

Jaundice:

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

Upper abdominal mass:

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

Investigations

FBC and ESR sent:

  • Yes
  • No

LFT, U&E sent:

  • Yes
  • No

Previous endoscopy done:

  • Yes
  • No

Upper GI cancer endoscopy guideline

Colorectal, Suspicion of 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

Rectal bleeding:

  • Yes
  • No

Passage of mucus:

  • Yes
  • No

Tenesmus:

  • Yes
  • No

Anal Symptoms:

  • Yes
  • No

Change in bowel habit greater than 4 weeks:

  • Yes
  • No

Abdominal mass palpable:

  • Yes
  • No

Rectal lesion palpable:

  • Yes
  • No
  • Not Applicable

If not applicable, please state reason: [Text]

Iron deficiency anaemia:

  • Yes
  • No

Family history:

  • Yes
  • No

Please provide details of onset and duration of symptoms: [Text]

For ‘Low Risk’ patients, please provide their next review date: [Date]

 

Investigations

Please indicate if the following have been checked:

FBC and U&E sent:

  • Yes
  • No

TFT, CRP, and Faeces Culture sent (diarrhoea only):

  • Yes
  • No

Recent E-GFR:

  • Yes
  • No

Suspicion of Colorectal Cancer Guidelines

Breast, Suspicion of 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

Date of Onset: Date

Priority: Urgent Suspicion of Cancer

Is this a fast track referral of a previous breast cancer:

  • Yes
  • No

Is there a suspicion of bilateral disease:

  • Yes
  • No

Will the patient accept any site for treatment:

  • Yes
  • No

Protocol Specific Questions

HRT History:

  • Never
  • Previously
  • Current

Number of years on HRT: [Text]

Menopause Status:

  • Pre-Menopausal
  • Menopausal
  • Post-Menopausal
  • Male patient or not applicable

Last Menstrual Period: [Date]

Is there a family history of breast cancer:

  • Yes
  • No

If yes to previous question, please give relationship and age at diagnosis: [Text]

Previous Mammograms: [Text (please provide date and location or N/A)]

Previous Ultrasounds: [Text (please provide date and location or N/A)]

Previous Breast Clinic appointments: [Text (please provide date and location)]

Breast Examination

Left Breast

Is there any left breast abnormality present:

  • Yes
  • No

Left breast abnormality: [Text (Please accurately describe the location and type of abnormality)]

Left breast degree of suspicion:

  • Uncertain
  • Probably Benign
  • Probably Malignant

Right Breast

Is there any right breast abnormality present:

  • Yes
  • No

Right breast abnormality: [Text (Please accurately describe the location and type of abnormality)]

Right breast degree of suspicion:

  • Uncertain
  • Probably Benign
  • Probably Malignant

Suspicion of Breast Cancer Guidelines

Advice Only Request 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 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

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.

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]

Addictions Referral Guidelines

Acne Referral 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]

Date of Onset: [Date]

Priority:

  • Routine
  • Urgent

Priority Reason: [Text – 98 character maximum]

Acne Severity:

  • Mild
  • Moderate
  • Severe nudulocystic

Acne referral guidelines