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]