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GP Referral Template

This document contains a national standardized patient referral template for hospitals. It includes sections for referral details, patient details, referrer details, clinical information, and a section for the hospital's use to track referrals. The clinical information section requests the reason for referral, symptoms, examination findings, relevant tests, past medical history, current medication, and additional relevant information.

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Anthony Tan
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100 views

GP Referral Template

This document contains a national standardized patient referral template for hospitals. It includes sections for referral details, patient details, referrer details, clinical information, and a section for the hospital's use to track referrals. The clinical information section requests the reason for referral, symptoms, examination findings, relevant tests, past medical history, current medication, and additional relevant information.

Uploaded by

Anthony Tan
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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National standardised patient referral template

Referral details Hospital: Specialty/Service: Preferred consultant/healthcare practitioner: Has the patient previously attended the hospital Priority (GP): Date of referral: Patient details Surname: First name: Address:

yes urgent routine

Date of birth: Gender: Next of Kin: Mobile number: Telephone (day): Telephone (evening): Hospital number: First language: Interpreter required: Wheelchair Assistance: Referrer details Name: Address:

yes yes

no no

Telephone: Fax: Mobile: Signature of referrer: Medical Council registration number: Patients usual GP (if different from Referrer details above) Name: Address:
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Clinical information Reason for referral/Anticipated outcome:

Symptoms (including history of presenting complaints and interventions to date):

Examination findings:

Relevant tests/investigations:

attached

not applicable

Past medical history:

Current medication:

Allergies/Adverse medication events

Relevant Family history:

Relevant Social history:

Additional Relevant information ( including special needs, disabilities, clinical warnings):

For hospital use (referral management and outcome) Date referral received: Date sent for triage: Date returned from triage:
Patients name: Patients date of birth: Referring GPs name:
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Triage outcome (priority): Date of new attendance: Consultant clinic:

urgent

soon

routine

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