Download 2WW Referral - RBFT Colorectal (Vision) v 0.8

Thames Valley
Cancer Network
2 Week Wait Referral for Suspected Colorectal Cancer
Patients should be fit enough, both physically and mentally, to undergo investigation. If in doubt – please
discuss with a Gastroenterologist
Please attach to the Choose and Book Unique Booking Reference Number (UBRN) within 24 hours
Referral Receipt Date:
Patient Details
Name: «PATIENT_Forename1» «PATIENT_Surname»
Email Address:
First Language:
Address:
«PATIENT_BlockAddress»
GP Details
GP Name:
Address:
«REFERRAL_Clinician»
«PRACTICE_Name»
«PRACTICE_BlockAddress»
Date of Birth: «PATIENT_Date_of_Birth»
Gender:
«PATIENT_Sex»
Ethnicity:
Interpreter Required:
Tel (Daytime): «PATIENT_Main_Comm_No»
Tel (Work):
Tel (Mobile):
NHS No:
«PATIENT_Current_NHS_Number»
Hospital No:
Tel No:
«PRACTICE_Main_Comm_No»
Fax No:
Date of referral: «SYSTEM_Date»
Date Referral Received:
Your patient will be seen under the 2 week rule if one or more of the following criteria are present.
Please tick the appropriate box(es) and add relevant details below.
RECTAL BLEED
Over 40
Change in bowel habit - Rectal bleeding with a change in bowel
Over 55
habit to looser and/or more frequent stools persistently for 6 weeks
No change in bowel habit Rectal bleeding persistently for more
than 6 weeks without a change in bowel habit and without anal symptoms
CHANGE IN BOWEL HABIT
Over 55
Looser and/or more frequent stools, persistently for more than
6 weeks without rectal bleeding
MASS
All Ages
All Ages
Abdominal - A definite palpable abdominal mass
Rectal - A definite palpable rectal (not pelvic) mass
Page 1 of 3 Vision v.0.8
RBFT FAX Number 01183226698
«PATIENT_Forename1» «PATIENT_Surname» «PATIENT_Current_NHS_Number»
Thames Valley
Cancer Network
ANAEMIA
To access 2WW service for this symptom and to justify an upper GI endoscopy and colon
radiology/colonoscopy you must include copies of the FBC result and ferritin with this referral
All Ages
All Ages
Men - Demonstrated iron deficiency with or without anaemia at any age
Women - Demonstrated iron deficiency with or without anaemia in a
non menstruating woman
Does the patient have diabetes?
Does the patient have renal failure?
Is the patient able to climb a flight of stairs unaided?
Yes
Yes
Yes
No
No
No
Additional Information
ORAL BOWEL CLEANSING AGENT ASSESSMENT SECTION
To be completed by the health professional requesting a procedure which may require an oral bowel cleansing agent
Absolute Contraindications – if yes to any of the Absoloute Containdications below please skip the rest of this section
GI obstruction ileus or perforation
Yes
No
Reduced conscious level
Yes
No
Dysphagia (unless via NG tube)
Yes
No
Hypersensitivity to any ingredient (Moviprep/Picolax)
Yes
Severe IBD
Toxic Megacolon
Ileostomy
No
Yes
Yes
Yes
No
No
No
Review the Blood Results
Mandatory - A recent (within 3 months) renal function measurement must be included to prevent any delays with
contrast CT scanning.
If you do not have this information please give the patient a bloods form for U&Es at referral
Date of Blood Test
Na
K
eGFR
eGFR-30-60
eGFR-15-29
eGFR-0-14
Co-morbidities / Risk Factors
Haemodialysis
Yes
No
Renal Transplant
Yes
No
Cardiac Failure
Yes
No
Hypertension
Yes
No
Pregnancy
Yes
No
Acute surgical abdominal conditions
Review Medications
ACEi/ARB
Diuretics
NSAIDs
Yes
Yes
Yes
No
No
No
Peritoneal
Electrolyte Imbalance
Liver Cirrhosis
Persistent Vomiting
Breastfeeding
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
No
No
No
No
Safe to stop for 72 hours?
Safe to stop for 24 hours?
Safe to stop for 72 hours?
If the medications cannot be stopped is it safe for the patient to have bowel prep? Yes
Page 2 of 3 Vision v.0.8
RBFT FAX Number 01183226698
No
«PATIENT_Forename1» «PATIENT_Surname» «PATIENT_Current_NHS_Number»
Thames Valley
Cancer Network
Additional comments – e.g. patient mobility
Allergies
«DRUG_ALLERGY»
Current Medication:
«REPEATS»
Other Relevant Medical History:
Additional Information
Additional reasons for requesting this referral:
Is the patient on an anti-coagulant?
Yes
No
Please state if you are attaching a letter / computer printout with this information: Yes
No
Is the Patient available for an appointment within the next 14 days:
Yes
No
Has the nature of this urgent referral been discussed with, and the
urgent two week wait referral leaflet given to, the patient:
Yes
No
1st OPA Required by:
62 Day Breach Date:
TO BE COMPLETED BY THE HOSPITAL
Type of bowel prep issued?
Picolax
Moviprep
Instruction provided to the patient:
Verbally
Leaflet
Yes
Yes
No
No
Authorising Consultant / Doctor
Signature ……………………………………………………
Patient fit for bowel prep
Signature ……………………………………………………
Page 3 of 3 Vision v.0.8
RBFT FAX Number 01183226698
«PATIENT_Forename1» «PATIENT_Surname» «PATIENT_Current_NHS_Number»