Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
NHS North Derbyshire and NHS Hardwick CCG PLCV Referral Form Cataract Surgery 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} Address Practice name ${Registered_GP_practice_name} Practice address ${Patient_address} ${Registered_GP_address} Post code ${Patient_post_code} Date of birth ${Date_of_birth} NHS Number ${NHS_number} Telephone number ${Registered_GP_phone_number} GP practice code ${Registered_GP_practice_ID} Part A - PLCV Criteria/declaration for Cataract Surgery FIRST EYE The CCG will fund cataract surgery where the visual acuity after refractive correction is 6/12 or worse in the worst eye (the eye to be treated). At least ONE must apply ☐ The patient has diabetes. The patient has Glaucoma and requires cataract surgery to control the intra ocular pressure Patients for whom good acuity is essential for their occupation e.g. watchmaker. Patients with posterior subcapsular or cortical cataracts who experience problems with glare and a reduction in acuity in bright conditions. Patients who need to drive and experience significant glare that is significantly related to the cataract which affects driving ☐ ☐ Patients with visual field defects borderline for driving, in whom cataract extraction would be expected to significantly improve the visual field. ☐ ☐ ☐ ☐ SECOND EYE The CCG will NOT fund cataract surgery in the second eye if the first eye has achieved a visual acuity of 6/9 or better, with refractive correction, and the acuity of the second eye is 6/18 or better with refractive correction. These patients should be reviewed by their optometrist annually or earlier if there is any deterioration in vision. The CCG will fund cataract surgery in the second eye if at least 1 of criteria 1 AND 1 of criteria 2 applies: Criteria 1 At least one must apply The first does not achieve an acuity of 6/9 or better, with refractive correction, and the procedure is clinically indicated for the patients individual circumstances. ☐ There are circumstances, where despite good acuities, there may still be a clinical need to operate on the second eye fairly speedily e.g. where there is resultant anisometropia (a large refractive difference between the two eyes) (≥ 2 dioptres and symptomatic) which would result in diplopia or an uncorrectable loss of acuity in the second eye (with first eye corrected) that effectively renders the second eye vision worse than 6/18. ☐ Criteria 2 At least one must apply The patient has diabetes. ☐ Patients who experience problems with glare and a reduction in acuity in bright conditions which affects driving. ☐ 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: Dear colleague, Preamble/context: ${Current_Consultation} Thank you, ${Referring_doctor} Problems ${Major_Active_Problems} ${Minor_Active_Problems} Relevant SH & FH: Date ${Todays_date} Smoking status Alcohol Occupation Ethnicity Veteran? ${RC_137..} ${RC_136..} ${RC_0....} ${RC_9i...} ${RC_13Ji.} Detail which might assist timely discharge: Medication – ${Todays_date} ${Current_Acute_Issues} Allergies – ${Todays_date} ${Allergies} Useful values: BP Pulse rate Height Weight BMI HbA1C ${RC_246..} ${RC_242..} ${RC_229..} ${RC_22A..} ${RC_22K..} ${RC_42W..} Systolic BP ${RC_2469.} Diastolic BP ${RC_246A.} ${Todays_date} ${Todays_date} Please embed any attached items here.