MULTIDISCIPLINARY Diagnostic Centre Referral Form

«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB: «PATIENT_Date_of_Birth» NHSno: «PATIENT_Current_NHS_Number» («PRACTICE_Name»)

MULTIDISCIPLINARY dIAGNOSTIC cENTRE Referral Form

MULTIDISCIPLINARY dIAGNOSTIC cENTRE Referral Form Page 1 of 4

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«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB: «PATIENT_Date_of_Birth» NHSno: «PATIENT_Current_NHS_Number» («PRACTICE_Name»)

REFERRALDATE:«REFERRAL_Event_Date»

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«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB: «PATIENT_Date_of_Birth» NHSno: «PATIENT_Current_NHS_Number» («PRACTICE_Name»)

Please send the referral form by email.

Please X the corresponding box for the hospital the referral is being made to and send within 24 hours.

Hospital / Phone / Email: select & copy OR <Ctrl>+click
North Middlesex / 07710 034 677 /
UCLH / 020 3447 5498 /

Patient has previously visited selected hospital HOSPITALNo:«REFERRAL_Hospital_number»

PATIENT DETAILS

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«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB: «PATIENT_Date_of_Birth» NHSno: «PATIENT_Current_NHS_Number» («PRACTICE_Name»)

SURNAME:«PATIENT_Surname» FIRSTNAME:«PATIENT_Forename1» TITLE:«PATIENT_Title»

GENDER:«PATIENT_Sex» DOB:«PATIENT_Date_of_Birth»

NHSNO:«PATIENT_Current_NHS_Number»

ETHNICITY:if(ethnicity.){ethnicity.#c}{} LANGUAGE:if(lang_spoke.){lang_spoke.#ac}{}

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«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB: «PATIENT_Date_of_Birth» NHSno: «PATIENT_Current_NHS_Number» («PRACTICE_Name»)

INTERPRETER REQUIRED TRANSPORT REQUIRED

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«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB: «PATIENT_Date_of_Birth» NHSno: «PATIENT_Current_NHS_Number» («PRACTICE_Name»)

PATIENTADDRESS:«PATIENT_House» «PATIENT_Road» «PATIENT_Locality» «PATIENT_Town» «PATIENT_County» POSTCODE:«PATIENT_Postcode»

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«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB: «PATIENT_Date_of_Birth» NHSno: «PATIENT_Current_NHS_Number» («PRACTICE_Name»)

DAYTIMECONTACT'*:

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«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB: «PATIENT_Date_of_Birth» NHSno: «PATIENT_Current_NHS_Number» («PRACTICE_Name»)

HOME':«PATIENT_Main_Comm_No» MOBILE'*:«PATIENT_Mobile_No» WORK':«PATIENT_Alt_Comm_No»

EMAIL:patient.email

CARER/KEY WORKER DETAILS

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«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB: «PATIENT_Date_of_Birth» NHSno: «PATIENT_Current_NHS_Number» («PRACTICE_Name»)

NAME: CONTACT': RELATIONSHIP TO PATIENT:

COGNITIVE, MOBILITY AND SENSORY

COGNITIVE SENSORY MOBILITY DISABLED ACCESS REQUIRED

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«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB: «PATIENT_Date_of_Birth» NHSno: «PATIENT_Current_NHS_Number» («PRACTICE_Name»)

PLEASE INCLUDE RELEVANT DETAILS:

GP DETAILS

USUALGPNAME:«PATIENT_Usual_GP»

PRACTICENAME:«PRACTICE_Name» PRACTICE CODE:

PRACTICEADDRESS:«PRACTICE_House» «PRACTICE_Road» «PRACTICE_Locality» «PRACTICE_Town» «PRACTICE_County» «PRACTICE_Postcode»

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«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB: «PATIENT_Date_of_Birth» NHSno: «PATIENT_Current_NHS_Number» («PRACTICE_Name»)

BYPASS':

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«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB: «PATIENT_Date_of_Birth» NHSno: «PATIENT_Current_NHS_Number» («PRACTICE_Name»)

MAIN':«PRACTICE_Main_Comm_No» EMAIL*:practice.email

REFERRINGCLINICIAN:«REFERRAL_Clinician» DIRECT TELEPHONE/MOBILE:

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«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB: «PATIENT_Date_of_Birth» NHSno: «PATIENT_Current_NHS_Number» («PRACTICE_Name»)

CLINICAL DETAILS

REASON FOR REFERRAL
The MDC is appropriate for patients with symptoms highly suggestive of cancer AND either
a.  Have concerning symptoms that do not fit an existing 2WW pathway OR
b.  Are too unwell to wait 2 weeks for first appointment but do not need admission.
I would like to refer the patient because (please specify or give details in consultation entry):
Please indicate one of the following categories:
New unexplained abdominal pain
Between 3 weeks and 6 months, unless very serious or urgent
A new persistent symptom OR
significant abdominal pain presenting at least twice in the previous month
Unexplained weight loss
Weight loss causing serious concern
Baseline weight
Amount of weight loss
Duration of weight loss
New and persistent unexplained nausea / loss of appetite
Please describe the reason for suspicion of cancer above
Painless jaundice
Bilirubin > 50 mmol/l
Not likely to be benign
GP gut feeling / persistent patient or family concern
Must describe the reason for suspicion above
HISTORY & PHYSICAL EXAMINATION
Physical examination findings:

Duration of symptoms:

Number of GP consultations with these symptoms:

Number of A&E visits with these symptoms:

Family History of cancer including age at diagnosis:

I confirm that I have discussed the possibility with the patient that the diagnosis may be cancer
I confirm that I have explained the appointment process to the patient, and the patient can be reached on the phone numbers provided.
Note: If you are concerned the patient cannot be contacted by phone, please phone MDC to arrange an appointment for the patient before they leave the practice.
Once seen at MDC, I confirm that I would like this patient to have on-going care at the trust if required.

Please hand the patient a copy of the RAPID ACCESS MULTIDISCIPLINARY DIAGNOSTIC CENTRE PATIENT INFORMATION LEAFLET

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«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB: «PATIENT_Date_of_Birth» NHSno: «PATIENT_Current_NHS_Number» («PRACTICE_Name»)

CLINICALLY-SPECIFIC AUTOMATIC TABULATED DATA

Blood Tests

Full Blood Count / Fbc.
Total Iron Binding Capacity / Tibc.
Serum Ferritin / Ferritin.
Urea and Electrolytes / Ue.
Liver Function Test / Liver.
Blood Glucose / bld_glucos.
HbA1c / hba1.
C Reactive Protein / c_react_pr.
Bone Studies / bone_stud.
Calcium / Calcium.

IMAGING STUDIES

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«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB: «PATIENT_Date_of_Birth» NHSno: «PATIENT_Current_NHS_Number» («PRACTICE_Name»)

Test(5,-51).(t)#abcd[Radiology/Physics in medicine] /
Date / Investigation / Qualifier / Comments /

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«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB: «PATIENT_Date_of_Birth» NHSno: «PATIENT_Current_NHS_Number» («PRACTICE_Name»)

Last Consultation

LastConsultation(-019).(1t)#!0 /
Date / Description /

Active Problems

Problems.(t)#ab[Known Problems] /
Date / Description /

Significant Medical History

Priority12.(t)#ab[Significant Medical History P1 and P2] /
Date / Description /

Current Repeat Medication

active.(t)#fbolh[Repeat Medication] /
Last Issued / Drug / Dosage / Qty / Iss /

Acute Medication in last 3m

RxAcute.(3mt)#adif /
Issued / Drug / Dosage / Qty /

Known Allergies

allergy.(t)#aiefg[Known Allergies] /
Date / Drug / Certainty / Severity / Reaction /

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