NHS STANDARD CONTRACT 2016/17 PARTICULARS (Full Length)
341 RHW ROYAL BERKSHIRE NHS FOUNDATION TRUST
Referral forPrimaryKneeJointReplacement
Please attachtotheChoose and Book UniqueBookingReference Number (UBRN)within72hours
NHS STANDARD CONTRACT
2016/17 PARTICULARS (Full Length)
25/04/16
NHS STANDARD CONTRACT 2016/17 PARTICULARS (Full Length)
341 RHW ROYAL BERKSHIRE NHS FOUNDATION TRUST
PatientDetails
Name: «PATIENT_Title»«PATIENT_Forename1»«PATIENT_Surname»
NHSNo:«PATIENT_New_Format_NHS_Number»
EmailAddress:
Address:
«PATIENT_BlockAddress»
Dateof Birth: «PATIENT_Date_of_Birth»
Gender:«PATIENT_Sex»
Ethnicity:
FirstLanguage:
InterpreterRequired:
Home Tel - «PATIENT_Main_Comm_No»
Work Tel -«PATIENT_Alt_Comm_No»
Mobile Tel - «PATIENT_Mobile_No»
Hospital No:«REFERRAL_Hospital_number»
NHS STANDARD CONTRACT
2016/17 PARTICULARS (Full Length)
25/04/16
NHS STANDARD CONTRACT 2016/17 PARTICULARS (Full Length)
341 RHW ROYAL BERKSHIRE NHS FOUNDATION TRUST
GPDetails
«PRACTICE_Name»
«PRACTICE_BlockAddress»
GP Name: «REFERRAL_Clinician»
Tel No: «PRACTICE_Main_Comm_No»
«PRACTICE_Fax_No»
Dateofreferral:«SYSTEM_Date»
NHS STANDARD CONTRACT
2016/17 PARTICULARS (Full Length)
25/04/16
NHS STANDARD CONTRACT 2016/17 PARTICULARS (Full Length)
341 RHW ROYAL BERKSHIRE NHS FOUNDATION TRUST
Has the patient had a previous primary knee joint replacement? Yes No
If No, has the patient either completed the Shared Decision Making process or been seen by the Arthritis Care Service prior to referral? Yes
If this is the patient’s first knee joint replacement please ensure the Shared Decision Making certification or Arthritis Care certificate is attached otherwise the referral will be sent back to the GP to ensure the patient has this completed process.
Is this a request for an opinion only?
If not attaching a letter please state what opinion is required:………………………………………………………………………………
Have the symptoms been present for longer than 3 months?
Are the patient’s activities of daily living affected by their knee pain?
Does the patient complain of persistent severe joint pain
and/or disturbed sleep despite optimum analgesia?
Has moderate or severe arthropathy been confirmed on X-ray?
Has patient had a minimum of 6 months’ conservative management?
Conservative management trialled:
Supported self-management Weight Loss Exercise Optimised analgesia
Are there any other joints that need treatment? Hip Ankle Contralateral Knee
Arethereanyconcerns aboutthe patient’s fitness for surgery?
Pleaseindicateifthepatienthas any of thefollowingconditions:
Hypertension: Heart Disease: Diabetes: Taking anticoagulants/Clopidogrel
Pleaseprovide details of thepatient’s current: BMI:«PATIENT_BMI» BloodPressure:«PATIENT_BP»
If BMI over 25 has the patient been offered and strongly encouraged to participate in a weight loss programme?
Yes No (patients with a BMI>40 may be high risk for surgery and therefore weight loss programme must be offered.)
Pleasestateifyou areattaching aletter/computerprintoutwiththis information:
Arethereexceptionalcircumstances forthispatient thatneeds tobeconsidered?
If yes, please explainexceptionality (START IMMEDIATELY BELOW – please keep document to 1 page):
Havetherisks andbenefits of surgery been discussed withthepatient prior toreferral?
Isthe Patient ready,willing and ableto completetheir treatmentwithinthe next18 weeks?Yes
NHS STANDARD CONTRACT
2016/17 PARTICULARS (Full Length)
25/04/16