Podiatry Referral Form

Podiatry Referral Form

Thank you for referring this patient to the podiatry service. The podiatrists will prioritise referrals according to need, using the information you provide. To help us provide an efficient service, please note that:

q  Referrals will only be accepted when completed by a member of the primary healthcare team.

q  Please either complete this referral form or send the same information in a letter.

q  Domiciliary visits are ONLY available for strictly housebound patients.

q  Please send the completed referral form to Podiatry Admin Offices at either:

Kempston Clinic, Halsey Road, Kempston, Bedford MK42 8AU OR

Liverpool Road Health Centre, 9 Mersey Place, Liverpool Road, Luton LU1 1HH

Patients will be offered an assessment appointment at which their needs will be assessed by a podiatrist and they will be advised accordingly. The assessment tool used by the podiatrists is reproduced on the reverse, for your information. You are not expected to apply it to your patients.

PATIENT / Mr Mrs Miss Ms Other / Date of birth:
First name(s): / NHS No:
Surname: / GP name:
Address:
Postcode: / GP address:
Postcode:
Telephone No: / GP Telephone No:
Reason for referral: / Medical history (including current medication)
(please tick which applies)
High risk group:
At risk pharmaceutically
At risk systemically eg steroids, warfarin, vascular disease, Raynaud’s, neurological deficit in feet, HIV, immunosuppressed
Low risk group eg arthropathies – causing foot pathology
All diabetic patients (please use diabetes referral form)
Referrer name
(Please print): / Signature:
Job title: / Referrer’s contact details:
Date:
Ethnicity: (if possible) Bangladeshi Black African Black Caribbean Chinese Indian
Not Known Not Stated Other Asian Background Other Black Background
Other Ethnic Group Other Mixed Background Other White Background Pakistani
White & Asian White & Black African White & Black Caribbean White British White Irish
First preferred language: /

Is an interpreter required?

FOR INFORMATION ONLY

To ensure a consistent approach to patient assessment for access to NHS provision, podiatrists use this Patient Assessment Tool, which is based on podiatric and medical need.

1.  Medical Need

A D B C

High risk group

At risk pharmaceutically
At risk systematically, eg
steroids; warfarin; vascular disease ie PVD; claudication; Raynauds. Neurological deficit in feet; HIV; immunosuppressed. / All diabetic patients
Insulin and non-insulin dependent /

Low risk group

Arthropathies – causing foot pathology / Factors which prevent bending

2. Podiatric Need (Grades 1-4: 1 = high need; 4 = low need)

1 2 3 4

Acute conditions

Ulcerations
Infections
Acute biomechanic problems / Chronic painful lesions
Fibrous lesions
Neurovascular corns
Moderate/heavy callous
Neurological callous
Chronic biomechanics
Foot deformities
Painful nails e.g.
Involution / Chronic non painful lesions
Minimal diffuse callous
Pressure points / Nail & skin conditions
Simple nail care
Care of dermatological conditions e.g. Fungal Psoriatic infections of skin and nails
Verrucae
Chilblains
Other nail pathologies e.g. onychogryphosis

Patient Assessment Matrix

Medical Need

/ A / D / B / C
Podiatric Need / 1 /
2
3 / /
4

1.  Patients in categories C3 and C4 will not qualify for NHS provision. The podiatrist will provide any advice and information which may be useful, to enable them to maintain their own basic foot care and be discharged from the system.

2.  Patients in categories B3 and B4 may not qualify for NHS provision, depending on their podiatric needs identified by the assessment.

3.  Patients in categories C1 and C2 should be devised a care plan which will lead to the resolution of the problem and a discharge from the system, e.g. nail surgery; orthotic/Insole with a short course of treatments.

4.  Patients in all other categories will have a treatment plan devised, appropriate to their needs, which will be reviewed on a regular basis and altered accordingly.