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