This form should be submitted via the Referral Support Service

Reference/Priority

Referral Date: 06 Nov 2020	Priority: 2WW	NHS Number:

Patient Details

Title:	Forename(s):	Surname:
Date of Birth: 03 May 1955	Gender:	Ethnicity:

Contact Details

Address Line 1:	Address Line 2	Address Line 3:
Town:	County:	Postcode:
Phone:	Mobile:	Text Message Consent:
Email:

Referrer/Practice Details

Referring Name:	Referrer Code:	Practice Code:

Referral Details

Specialty: 2WW	Clinic Type: 2WW Lower GI	Named Clinician:

Patient Choice Preferences

Provider 1:	Provider 2:

Preferences

Assistance Required:	Assistance Notes:	Confidential/Silent Referral:
Preferred Contact Time:	Interpreter Required:	Preferred Language: language not specified

Referral Details

Non-clinical information for the booking team:
Provisional Diagnosis:
Smoking Status Readcode: 07 Jul 2020, Never smoked tobacco (XE0oh)

Referral Reason/Letter Text

Patient Awareness

Confirm that your patient understands that they have been referred onto a “suspected cancer pathway” and may need invasive investigations:
Confirm that your patient has received the information leaflet
Confirm the patient is a suitable candidate for telephone assessment
Confirm the patient has been informed that they may be straight to test which is an invasive test
Confirm the patient is aware they may not be seen by a clinician
Confirm the patient is available to attend an appointment or an investigation within 2 weeks of this referral and if necessary subsequent appointments over the next few weeks**

Reason for Referral

NICE recommended refer fast track if
Age ≥ 40 unexplained weight loss and abdominal pain
Age ≥ 50 unexplained rectal bleeding
Age ≥ 60 persistent change in bowel habit (looser stool, increased frequency or constipation)
Age ≥ 60 iron deficiency anaemia (confirmed by haemoglobin and ferritin levels)
Tests show occult blood in their faeces (FIT/FOB)

NICE recommend consider fast track referral if
Any age abdominal mass or rectal mass (refer pelvic mass to gynae and upper abdominal mass use upper GI fast track form) Attach scan report if already performed
Age ≤ 50 with unexplained rectal bleeding and
abdominal pain
change in bowel habit (looser stool, Increased frequency or constipation)
weight loss
iron deficiency anaemia (confirmed by haemoglobin and ferritin levels)
Any age unexplained anal mass and/or anal ulceration

History

Please enclose as much information as possible about the presentation and the patient’s performance status
PLEASE ENSURE A FIT TEST IS REQUESTED WITH ALL REFERRALS EXCEPT ANAL MASS AND/OR ANAL ULCERATION
PLEASE ENSURE BLOODS FOR FBC, U&E’s, CRP AND FERRITIN ARE ALSO REQUESTED IF NOT ALREADY DONE SO

Risk of Cancer

GPs VIEW OF RISK OF CANCER WHERE 1 IS LOW RISK AND 10 IS HIGH RISK

Abdominal Examination

Normal Findings
If abnormal findings, please document any masses felt during examination:

Digital Per Rectum Examination

Normal Findings
If abnormal findings, please document any masses felt during examination:

WHO Performance status (helps to decide fitness for specific tests)

0 = Fully active, able to carry out all pre-disease performance without restriction
1 = Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature e.g. light house work, office work
2 = Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours
3 = Capable of only limited self-care, confined to bed or chair more than 50% of waking hours
4 = Completely disabled. Cannot carry out any self-care. Totally confined to bed or chair

Referral Checklist - ***THIS MUST BE COMPLETED PRIOR TO REFERRING THE PATIENT***

Referral Letter (see page 2)
Abdominal and DPR examination performed
Performance status
Past Medical History
Current Medications
Allergies/Sensitivities
Blood tests
FIT test requested (except anal mass)
Weight
Patient’s contact telephone number

YORK TEACHING HOSPITAL NHS TRUST
Primary Care CT Scan Referral

Incomplete requests could delay this examination or result in an incomplete investigation

Patient Information Patient Name: NHS Number: DOB: Gender: Address: Telephone Number: Mobile Number:	From April 2018 all patients needing IV contrast for CT need to have a Creatinine and eGFR no more than 3 months prior to their scan. Please either provide the results below and date of test *Serum Creatinine: (XE2q5), 70 umol/L 19 May 2014, _EMIS_MHS, Serum creatinine level (XE2q5), 67 umol/L 07 Aug 2014, _EMIS_MHS, Serum creatinine level (XE2q5), 66 umol/L 26 May 2015, _EMIS_MHS, Serum creatinine level ( OR: Order bloods and tick the box Requests may not be processed until results are available to us Consider renal prophylaxis, if creatinine > 150 μMol AND eGFR < 45 ml /min / m2 Examinations not requiring IV contrast are CT KUB CT sinuses CT head (unless looking for metastases) HRCT of the chest Orthopaedic CT
Examination requested (see CCG guidelines): Freetext: Patient is on a fast track pathway Yes
Clinical details and diagnosis:
Diabetic? Is the patient on Metformin? Yes No If diabetic and on metformin, please ensure creatinine & eGFR (<3 months old) are provided.
This request been discussed with a consultant? Who? This test is part of a CCG approved pathway Which one? This test has been suggested by a specialist team Who?	Possible pregnancy? Disability? Yes Hearing Visual Learning Please describe mobility: Walking Trolley Chair Bed Hoist O2
Weight
Referring Clinician Requests only accepted from Trust approved referrers - Ionising Radiation (Medical Exposure) Regulations 2000 GP Practice: GMC Registration Number / NMC short code: (compulsory for email requests) Date of referral:

Patient ID Label Here

For Radiology Use Only Urgent ☐ Soon ☐ Routine ☐ Authorised by: Practitioner: Operator: Scan type: Comments: IV Contrast: Y ☐ N ☐ Oral Contrast: Y ☐ N ☐ Oral Prep Volume: 500ml / 1000mls / 800mls Omnipaque 350 ☐ Gastrografin ☐ Water ☐ Klean Prep ☐ EZ CAT ☐ Radiology appointment date & time: For Radiology Use Only ID check Name ☐ DoB ☐ Address ☐ Wristband ☐ ID checked by - Name of Staff: Operator: Room: Dose: mAs* mGy.cm²* (* Please circle as appropriate) Pregnancy Status There is no possibility that I am pregnant (signature): Date: 1st day of LMP: THE 10/28 DAY RULE APPLIES Checked by (staff): Date: Decision to over-rule (Dr): Reason: Oral contrast check Name ☐ DoB ☐ allergies ☐ omnipaque ☐ kleanprep ☐ ezcat ☐ water ☐ gastrografin ☐ Vol given by: 500 / 1000 / 800mls IV contrast and buscopan check allergies* ☐ asthma ☐ diabetic ☐ metformin ☐ hyperthyroidism ☐ buscopan ☐ mys gravis ☐ heart / bp ☐ glaucoma ☐ bladder outflow ☐ obstruction ☐ Agent: lot no: Given by: *Comments (including details of patient allergies):

CT appointments: York: (01904) 725936 ext. 5936 Scarborough: (01723) 342044 ext 2044