Download Hepatitis Checklist and Referral Form

Hepatitis Checklist and Referral Form
Contact
details:
GSTT
KCH
Other
Address
Phone
Fax
Email
Referral Date
Referring Clinician
Practice Details
~[Today...]
~[Free Text:Referring
Clinician?]
~[Surgery Address Line
1]
~[Surgery Address Line
2]
~[Surgery Address Line
3]
~[Surgery Address Line
4]
~[Surgery Address Line
5]
~[Surgery Tel No.]
Patient Name
DOB
~[Forename] ~[Surname]
~[Date Of Birth]
Patient Address
~[Patient Address Block]
Patient Tel
Mobile
NHS Number
Hospital Number
~[Telephone Number]
~[Mobile]~[Mobile Number]
~[NHS Number]
~[Hospital Number]
History
How long has this patient been registered at your practice?
Date exposure took place (if known)?
How was the patient exposed/method of transmission (if known)?
Has this patient been treated for hepatitis B or C in the past? Which centre?
Have contacts/family members been informed? Advice given to patient regarding safe sex?
Alcohol history (units/week):
FAST questionnaire score:
Smoking history:
Final March 2013
Please complete hepatitis B+C serology for all patients and document results fully below
Decision Matrix for Hep B (NICE)
Hepatitis
(Please tick)
HBV
REFER / INFORM SPECIALIST SERVICES IF:
Surface antigen test positive* All individuals with HBV SAg +ve should be referred
(the term ‘carrier’ is misleading)
eAntigen positive
PRIOR TO REFERRAL, PLEASE COMPLETE AND DOCUMENT/ATTACH
Liver function tests, including AST and GGT
DNA titre
AFP
HIV test
Ultrasound
*Individuals with HBV s Ag –ve & cAb +ve alone have cleared HBV spontaneously,
repeat test to exclude false positive
Final March 2013
REFER / INFORM SPECIALIST SERVICES IF:
HCV
HCV RNA positive** include level: ____________
PRIOR TO REFERRAL, PLEASE COMPLETE AND DOCUMENT BELOW
Genotype
Liver function tests, including AST and GGT
AFP
HIV test
Ultrasound
**15-20% of patients will clear HCV (HCV RNA negative) – these individuals do not have
chronic HCV and so do not need referral
PLEASE perform HIV testing for all patients prior to referral. If not possible please
DISCUSS need for HIV test
Have patient’s family members and close contacts been screened and vaccinated?
( YES/NO/NOT TESTED)]
GP comments (including any other relevant information):
~[Free Text:Any other Comments including Relevant History?]
Diabetes (year of diagnosis and recent HbA1c)
Weight / BMI ~[ReadCode:22A~1Y~~R~Date|Free Text~1]/~[ReadCode:22K~1Y~~R~Date|Free Text~1]
Blood pressure ~[Blood Pressure:1]
Medications ~[Medication]
Allergies ~[Allergies]
Final March 2013