Incomplete Referrals Will Require Us to Contact You by Phone for Missing Information, This

NHS

Hertfordshire Community Health Services

Single Point of Contact (SPOC) Referral Form

Hertfordshire Community Diabetes Service

INCOMPLETE REFERRALS WILL REQUIRE US TO CONTACT YOU BY PHONE FOR MISSING INFORMATION, THIS COULD RESULT IN A DELAY IN PROCESSING YOUR REFERRAL
NB. Patients are not to be referred to the Community Diabetes Service for routine QOF Annual Reviews
This form is to be used for all non-emergency referrals for people with T1DM or T2DM, who are requiring an enhanced level of specialist diabetes management
Submit form via Choose and Book OR Fax 01707 621178 OR Email OR Mail Community Specialist Diabetes Service, Potters Bar Hospital, Potters Bar, EN6 2RY (Tel 01707 621152)
(If attaching this referral form to an email, please email ONLY from an nhs.net email address for patient confidentiality. Other emails addresses are not secure.)
1.  Unwell Newly Diagnosed? Is the patient unwell with ketones present in the urine?
If YES please refer immediately to the on-call Medical Registrar
2.  “Acute Foot” – refer immediately to On-call medical registrar
*e.g. sign of infection (such as cellulitis or osteomyelitis) not responding to standard first-line GP care
3. Diabetes and Pregnancy – refer urgently to antenatal clinic (will liaise with hospital specialist diabetes services)
4. In exceptional circumstances, you may wish to refer to a particular consultant or clinic. Please state your reasons here. The triage team may ring you for clarification within 72 hours.
Patient Details / GP Details
(NB: Indicate preferred recipient of letters from clinic)
Surname: ~[Surname] / Referrer: ~[Free Text:FULL name of who is referring:]
Forename (s): ~[Forename] / GP name: Dr ~[Free Text:GP to whom letters should be sent back]
Preferred Calling Name: ~[Calling Name]
DOB: ~[Date Of Birth] Age: ~[Patients Age]
NHS Number: ~[NHS Number]
Address: ~[Patient Address Line 1]
~[Patient Address Line 2]
~[Patient Address Line 3]
~[Patient Address Line 4]
~[County]
Postcode ~[Post Code] / Surgery: ~[Surgery Address Line 1]
~[Surgery Address Line 2]
~[Surgery Address Line 3]
~[Surgery Address Line 4]
~[Surgery Address Line 5]
Telephone: ~[Surgery Tel No.]
Fax:
Telephone ~[Telephone Number] / Referral Date: ~[Today...]
Mobility Problems?
Visual Impairment?
Hearing Impairment?
Learning Disability?
Cognitive Problem? / Next of Kin name (if known):
NoK Relationship (if known):
NoK Phone no. (if known):
Lives alone?
Any risks to lone worker? None known:
Yes
If YES: details

Translator required?

Specify language: ~[Free Text:Spoken language (if non-English speaker)]

Ethnicity:

~[ReadCode:9i~20Y~~R~Coded Data~0]

~[ReadCode:9S~20Y~~R~Coded Data~0]

Reason for Referral (tick as many as you feel are required)
Patient education: T2DM (e.g DESMOND for new and established patients)
Patient education: T1DM (e.g DAFNE etc )
Special Dietetic Advice (NOT routine advice )
Individual Podiatry Assessment (NOT routine check)
Hyperglycaemia / High HbA1c
Oral Medication Optimisation
Incretin Mimetic / GLP-1 Analogue consideration (eg exenatide, liraglutide)
Insulin Management
Insulin Initiation
Hypoglycaemic episodes (eg if on sulphonylureas or insulin)
Device Management & Support (eg pens, machines, aids if rheumatoid or blind )
Transient Complex Medical Problems (eg steroid use in PMR, terminal care)
Other
Identified Diabetic Complications
No currently identified diabetic complications
The patient has identified diabetic complications
Diabetic nephropathy / details?
Diabetic retinopathy / details?
Diabetic foot neuropathy / details?
Other diabetic complications / details?
History of MI or other ischaemic heart disease? Yes No
History of CVA or TIA? Yes No
History of Peripheral Vascular Disease? Yes No
FOR COMPLETION AT THE SPOC (Single point Of Contact)
Referral redirected to Secondary Care Service via Choose and Book – reason:
Complex diabetes / Acute Foot / Renal / Other
specify
Appointment priority (please tick) / within 24 - 48h / within 1 week / within 1 month / within 2 months
Diabetes Nurse Consultant / Specialist Nurse Clinic
Consultant Community Clinic
Combined Consultant / DSN Clinic
Preconception Clinic
Podiatrist
Dietitian

(Please email ONLY from an nhs.net email address for patient confidentiality. Other emails addresses are not secure.)

Hertfordshire Community Diabetes Service SPOC Referral Form v3.0 (Apr2010 EMIS-LV)

Summary for ~[Title] ~[Calling Name] ~[Surname] (NHS number: ~[NHS Number])

Date: ~[Today...] Page 1 of 4

Please dispose of any versions pre-v3.0

An EMIS LV printout is acceptable if this data is not automatically added.

Weight (kg) – last three recorded entries

~[ReadCode:22A~~M3~R~Coded Data|Date~1]

BMI (kg/m2) – last three recorded entries

~[ReadCode:22K~~M3~R~Coded Data|Date~1]

Blood Pressure – last three recorded entries

~[Blood Pressure:3]

Current Smoking Status – date of last recorded entry

~[ReadCode:137~~M1~R~Date|Coded Data|Free Text~1]

Glycaemic Control

HbA1c (DCCT aligned) – last three recorded entries

~[ReadCode:42W4~~M3~R~Date|Coded Data~1]

HbA1c (IFCC standardised) – last three recorded entries

~[ReadCode:42W5~~M3~R~Date|Coded Data~1]

Plasma Fasting Glucose – last three recorded entries

~[ReadCode:44g1~~M3~R~Date|Coded Data~1]

Lipids – last two years

Serum Total Cholesterol

~[ReadCode:44P~2Y~~R~Date|Coded Data~1]

Serum LDL Cholesterol

~[ReadCode:44P6~2Y~~R~Date|Coded Data~1]

Serum Triglycerides

~[ReadCode:44Q~2Y~~R~Date|Coded Data~1]

Renal Function – last three recorded entries

Serum Sodium

~[ReadCode:44I5~~M3~R~Date|Coded Data~1]

Serum Potassium

~[ReadCode:44I4~~M3~R~Date|Coded Data~1]

Serum Urea

~[ReadCode:44J9~~M3~R~Date|Coded Data~1]

Serum Creatinine

~[ReadCode:44J3~~M3~R~Date|Coded Data~1]

eGFR (MDRD formula)

~[ReadCode:451E~~M3~R~Date|Coded Data~1]

UACR (Urine Albumin:Creatinine Ratio)

~[ReadCode:46TC~~M3~R~Date|Coded Data~1]

Liver Function – last three recorded entries

Alkaline Phosphatase

~[ReadCode:44F~~M3~R~Date|Coded Data~1]

ALT/SGPT

~[ReadCode:44G3~~M3~R~Date|Coded Data~1]

Serum Gamma-GT

~[ReadCode:44G9~~M3~R~Date|Coded Data~1]

Thyroid Function – last two recorded entries

Serum Thyroid Stimulating Hormone

~[ReadCode:442W~~M2~R~Date|Coded Data~1]

Serum free-T4 level

~[ReadCode:442V~~M2~R~Coded Data|Date|Free Text~1]

Haemoglobin – last recorded entry

~[ReadCode:423~~M1~R~Coded Data|Date|Free Text~1]

Retinal Screening – date of last recorded episode – and coded outcome (if recorded)

~[ReadCode:68A8~~M1~R~Date|Coded Data|Free Text~0]

~[ReadCode:2BB~~M2~R~Coded Data|Date|Free Text~0]-

Active Problems – active significant, active minor and past significant problems

~[Active Problems:AS~AM~PS~FT]

Current Prescribed Medication (no current prescribed medication if this section is blank)

~[Medication]

Recorded Allergies (no allergies have been recorded in EMIS if this section is blank)

~[Allergies]

Hertfordshire Community Diabetes Service SPOC Referral Form v3.0 (Apr2010 EMIS-LV)

Summary for ~[Title] ~[Calling Name] ~[Surname] (NHS number: ~[NHS Number])

Date: ~[Today...] Page 1 of 4

Please dispose of any versions pre-v3.0