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