NHS North Derbyshire and NHS Hardwick CCG PLCV Referral Form

Carpal Tunnel

THIS FORM MUST BE COMPLETED IN FULL AND SUBMITTED WITH THE APPROPRIATE CLINICAL INFORMATION

Patient details / Referring GP details
Surname${Surname} / Referring GP${Referring_doctor}
Forename(s)${Forename} / Practice name${Registered_GP_practice_name}
Address
${Patient_address}
Post code${Patient_post_code} / Practice address
${Registered_GP_address}
Date of birth${Date_of_birth} / Telephone number${Registered_GP_phone_number}
NHS Number${NHS_number} / GP practice code${Registered_GP_practice_ID}
Part A - PLCV Criteria/declaration for Carpal Tunnel
The CCG will only fund referral for carpal tunnel if eithercriteria 1 or ALL of criteria 2 are met.
If any of the following are present refer urgently to secondary care:-
  • Evidence of thenar wasting
  • permanent numbness
  • symptoms are severe/frequent/functionally impairing
  • the condition makes daily activities impossible
  • If symptoms occur in the presence of neurological disease, inflammatory joint disease, periperhal limb ischaemia or cervical nerve root entrapment

Criteria 1 (patients to be referred urgently if meet both criteria 1) / MUST apply
Patients with a score of 5 or more on the CTS Boston questionnaire / ☐
Criteria 2 / ALL must apply
Patients with a score of 3 or 4 on the CTS Boston questionnaire / ☐
Patient has had 12 week trial of neutral wrist splinting or has had a trial of single steroid injection with no relief of symptoms .
Please note urgent referral required if symptoms are deteriorating before this point. / ☐
Additional information
Additional Patient Information / Both must apply
This patient is willing to undergo a surgical procedure should it be offered. / ☐
I have discussed with the patient the fact they will be referred for a possible procedure but there is no guarantee that a surgical intervention will be the preferred outcome following the consultation with the secondary care specialist. / ☐
I confirm that the patient meets the current clinical guideline/policy for referral for the procedure
Name of referrer ${Referring_doctor}
Date ${Todays_date}
Part B
Reason for referral:
Salutations:
Preamble/context: / Dear colleague,
${Current_Consultation}
Thank you,
${Referring_doctor}
Problems
${Major_Active_Problems}

${Minor_Active_Problems}

Relevant SH & FH:

Date
Smoking status
Alcohol
Occupation
Ethnicity
Veteran?
Detail which might assist timely discharge: / ${Todays_date}
${RC_XE0og}
${RC_Ub0lD}
${RC_0….}
${RC_ XaJQu}
${RC_ XaX3N}

Medication– ${Todays_date}

${Current_Acute_Issues}

Allergies– ${Todays_date}

${Allergies}

Useful values:

BP
${RC_246..}
Systolic BP
${RC_2469.}
Diastolic BP
${RC_246A.}
${Todays_date} / Pulse rate
${RC_242..} / Height
${RC_229..} / Weight
${RC_22A..} / BMI${RC_22K..} / HbA1C
${RC_X772q}
${Todays_date}
Please embed any attached items here.