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