Tag: template

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