Download Patient name - Sheffield PRESS Portal

REFERRER CHECK LIST as appropriate
New patient
Patient already on caseload
Past medical history attached
Medication list attached
Spirometry results attached
Last five consultations attached
SINGLE POINT OF ACCESS (SPA)
DEMOGRAPHICS AND REASON FOR REFERRAL
Date of first visit/urgency of visit (as appropriate):
Patient name:
………………..……………………………………………..
Title:
National Health Service Number (NHS No.)
Gender:
Male/Female
Date of Birth (D.O.B.)
Current address:
Postcode:
Telephone number:
Does this patient live alone?
City Wide Alarms:
Yes/No
Special information to access the property:
Risks:
Key Safe/Door Code:
Additional info:
Next of kin – Name:
Relationship:
Ethnicity:
Telephone Number:
Religion (if known):
General Practitioner (GP)/Consultant:
Does the next of kin wish to be
notified prior to visit:
Yes/No
First language:
Interpreter needed?:
GP Telephone Number:
GP Fax Number:
GP Practice Name/Address:
Date last seen by GP:
Consent to share information with appropriate service: Yes
Reason for referral:
Referrer:
Print Full Name:
Designation:
Telephone Number:
Please send SPA by fax on 0114-305-1461, or by mail to SPA at Lightwood House, Sheffield, S8 8BG, or phone 0114 305 1460
Version 1.0: May 2013
APPENDIX F: PULMONARY REHABILITATION REFERRAL
Patient name:
NHS Number/D.O.B:
Please state whether patient is being referred for: For Early supported discharge referrals please state date of discharge from
hospital :
Group Pulmonary Rehabilitation 
Home based (state reason e.g. housebound/
anxiety) 
Respiratory diagnosis:
Does the patient have
chest pain?
Yes/No
Is the patient aware of their diagnosis?
Yes/No
If present has the chest pain been
investigated?
Yes/No
GTN used and in date?
Previous type II failure?
Yes/No
Yes/No
MRC (Medical Research Council) SCALE (circle as appropriate)
Referral criteria is functionally limited breathlessness - usually MRC 3 or above
1. only get breathless with strenuous exercise,
2. get short of breath hurrying on level or uphill,
3. walk slower than people same age or have to stop due to breathlessness,
4. have to stop after a few hundred yards of walk due to breathlessness,
5. too breathless to leave house or get breathless getting dressed/undressed.
Previous Pulmonary rehabilitation
Yes (when? ……………………..)
No
Don’t know
Does the patient have any serious disability or mobility problems, or severe arthritic limitations to exercise, or other limitations to
exercise, e.g. CVA, amputation, etc: YES/NO
If Yes, please state limitation:
Patient receiving oxygen Long term oxygen
therapy? Yes/No
therapy (LTOT)? Yes/No
Prescription l/min
if available
Ambulatory oxygen?
Yes/No
Prescription l/min
IF not on LTOT
If on LTOT
Oxygen saturations on
air:
Oxygen saturations on
LTOT:
If available
PLEASE COMPLETE FOLLOWING INFORMATION ONLY IF NOT SHARING ON TPP
Are there any services already involved with this patient?
Past Medical History: Please attach full past
medical history
Medication: Please attach list of current medications
Any known allergies?
Latex allergy? Yes/No
MRSA status? Positive/Negative/Unknown
Pulse:
Rhythm: Regular/Irregular
Blood pressure:
Spirometry:
Please attach report if not scanned on TPP:
% predicted FEV1:
% predicted FVC:
Ratio:
Please see attached inclusion/ exclusion criteria sheet for reference
Please send SPA by fax on 0114-305-1461, or by mail to SPA at Lightwood House, Sheffield, S8 8BG, or phone 0114 305 1460
Version 1.0: May 2013
For enquiries please telephone Active Programmes Team on 0114 305 4200
Pulmonary Rehabilitation Referral Criteria and Exclusion criteria
The following are inclusion criteria for pulmonary rehabilitation:
*Guidance is given in italics
Diagnosed respiratory condition i.e. COPD, Bronchiectasis, Pulmonary Fibrosis.
Functionally limited by their disease, usually MRC grade 3 or above.
Asthma *may be considered – liaise with team
Pre and post lung resection *may be considered –liaise with team
Post chest trauma *may be considered –liaise with team
The following are exclusion criteria for pulmonary rehabilitation
*Guidance is given in italics
Unstable Angina
Unresolved chest pain
Myocardial Infarction within the last 6 weeks
*refer to cardiac rehabilitation unless otherwise indicated
Severe cardiac arrhythmias or uncontrolled arrhythmias
History of supraventricular tachycardia
Tachycardia (HR >100)
Bradycardia (HR< 60 not betablocked)
Uncontrolled heart failure
Moderate to severe Heart failure
*If Mild/ Moderate heart failure please forward a copy of most recent ECHO report
Hypertrophic cardiomyopathy
Severe Aortic Stenosis – or if symptomatic at any severity.
*If mild/ moderate require confirmation via ECHO within past 6 months and confirmation of
safety to exercise from cardiologist.
Active endocarditis
Aortic aneurysm >5cm
*if less than 5cm will need to have had review within past 6 months and confirmation of
suitability to exercise from cardiology
Uncontrolled medical co morbidities
Hypertension >180 systolic / 100 diastolic
Hypoxia, Spo2 at rest <92% unless has supplementary oxygen
* refer for LTOT assessment as appropriate
Cataract surgery within 2 weeks (contact opthalmology if any concerns)
Acute, recurrent or suboptimally managed Pulmonary embolism
Acute thrombosis of extremity
Pulmonary hypertension without confirmation from consultant on safety to exercise.
* Need guidelines from consultant for level of acceptable oxygen desaturation on exertion
History of cardiac arrest not associated with surgical procedure
Cardiac defibrillator insitu
*please refer to cardiac rehabilitation
LTOT but no ambulatory oxygen
* refer for ambulatory oxygen assessment prior to pulmonary rehabilitation referral if LTOT in
situ without ambulatory oxygen
Syncope
Dizziness without investigation
Spirometry not done in last 12 months
Electrolyte imbalance
*please liaise with team
Acute confusion
Chronic confusion/ memory difficulties without the support of a carer
Please send SPA by fax on 0114-305-1461, or by mail to SPA at Lightwood House, Sheffield, S8 8BG, or phone 0114 305 1460
Version 1.0: May 2013