Download Referral Form - ICID (Salisbury)

SALISBURY NHS FOUNDATION TRUST
RADIOLOGY REFERRAL FORM
Patient Details (Affix label if available)
Surname
Forename
Male / Female
Date of Birth
Address
Post Code
Telephone Number
GP Name
Reasons for Referral / Clinical Details
Note: As a Referrer under the Ionising Radiation Medical Exposure Regulations
2000 you are responsible for providing sufficient information to allow for
identification of the patient and justification of the examination. If you do not do this,
the request will be returned.
Referrer Details
Surname
Consultant /Practice Name
Initials
Clinical Team /Practice Address
Status
Bleep /Phone Number
Hospital registration Number
NHS Number
IP Ward
OP Clinic
Walking
Chair
NHS
PP
Stretcher
Mobile
Research
Category II
Theatre
Medico Legal
For CT, MRI and other Intra Venous Contrast enhanced examinations
Is the patient likely to have abnormal renal function? Yes / No
If Yes
GFR:
Creatanine Level:
Examination Requested
Date of Measurement:
FAILURE TO SUPPLY THIS INFORMATION MAY RESULT IN INAPPROPRIATE
OR DELAYED INVESTIGATION OF THIS PATIENT
Communication needs
Referrers Signature
Ver 3.1
Date
Oral Bowel Cleansing Agent Prescription Checklist
Name:
Address:
Date of Birth:
Hospital Number:
Procedure:
Colonoscopy
CTC
This checklist is to be completed by the referring clinician
and a copy should then be filed in the patient’s medical
records.
Barium Enema
Capsule Study
Small Bowel Meal
Other
Step 1: Absolute Contraindications
GI Obstruction, ileus or perforation
Severe Inflammatory Bowel Disease
Toxic Megacolon
Reduced conscious level
Hypersensitivity to any ingredients
Dysphagia (unless via NGT)
Ileostomy
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Step 4: Consider Co-Morbidities & Risk Factors
Co-Morbidities
Kidney Disease
CKD 3
CKD 4
CKD 5
Haemodialysis
Peritoneal Dialysis
Renal Transplant
Electrolyte
Imbalance
If yes to any question, do not continue
Optimal Bowel Cleansing
Klean Prep / Picolax
Klean Prep (if fluid status
allows)
Klean Prep (if fluid status
allows)
Discuss with nephrologist
Discuss with nephrologist
Discuss with nephrologist
Acceptable
Picolax
Picolax
Picolax
Klean Prep
Picolax
Klean Prep
Picolax
Klean Prep
Picolax
Cardiac Failure
Step 2: If patient likely to have abnormal blood test Review the Blood results
Na
eGFR 30-60 = CKD 3
K
eGFR 15-29 = CKD 4
eGFR
eGFR 0-14 = CKD 5
If abnormal blood results, refer to Step 4
Liver Cirrhosis
Hypertension
Klean Prep / Picolax
Step 5: Other Comments:
Step 3: Review Medications
ACEi/ARB
Diuretics
NSAIDs
Lithium*
Yes / No
Yes / No
Yes / No
Yes / No
Safe to stop for 72 hrs?
Safe to stop for 24 hrs?
Safe to stop for 72 hrs?
Safe to stop?
Yes / No
Yes / No
Yes / No
Yes / No
Step 6: Type of Bowel Prep to be Issued: Picolax / Klean Prep
(Picolax is the bowel cleansing solution of choice for most patients)
Step 7: Instructions provided to patient Yes / No
Step 8: Signature..............................................................................
Print Name
Designation
Date
KEY: ACEi Angiotensin converting enzyme inhibitors, ARB Angiotensin II Receptor Blockers, CKD chronic kidney disease, (Taken from BSG, 2009) RAF, HMD, JS, 2010.
*Lithium levels and toxicity may be increased by the fluid and electrolyte imbalance caused by administration of the bowel preparation. Check the most recent lithium level and
make a clinical decision whether to omit any doses of lithium, if the lithium level is high, advice should be sought from the pt’s psychiatrist