BNSSG Musculoskeletal (MSK) Service

Single Point of Access Referral Form

1) Please complete this referral form for musculoskeletal patients in as much detail as possible. If referring for a condition that requires surgical intervention you must provide evidence to support the referral Criteria Based Access (CBA) or Prior Approval.

The full list of conditions/joints involved and the complete policies can be found at:

2) This form is mandatory for all referrals for MSK Physiotherapy, MSK Podiatry and Orthopaedic Interface Servicesin Bristol (MATS & MATS Spinal service), South Gloucestershire (CATS/SATS) and North Somerset Community Partnership (NSCP)

3) Emergency referrals should continue to be made by telephone to the relevant on call team or via Accident and Emergency Department.

4) If you suspect Inflammatory Arthritis refer directly to secondary care.

Patient details (These boxes must be completed or the referral will be rejected)
Surname:Surname / Forenames(s):Given Name
Patients Address:
Home Full Address (stacked) / Contact
Numbers: / Home: Patient Home Telephone
Mob: Patient Mobile Telephone
Patient gives consent for a message to be left on an answer machine or family member regarding an appointment - this will not include any confidential clinical information:
YesNo
NHS No: NHS Number / Date of Birth:Date of Birth
Gender:Gender(full) / Ethnicity: Ethnic Origin

Blood Pressure

BMI

Smoking

GP/Referrer details
Referring GP/Clinician:Free Text Prompt / Practice Address:
Usual GP Full Address (stacked)
CCG:Current CCG
Telephone:Usual GP Phone Number
Special needs of patient: Are there any issues that we should be aware of regarding patient communication
Interpreter Disability access Carer support Other
Has the patient previously been identified as having high anaesthetic risk?YesNo
If yes, please specify:

Problems

Medication

Allergies

Consultations

MSK Referral information
Reason for MSK referral
Spinal Interface Peripheral joint Interface PhysiotherapyMSK Podiatry
If this is an MSK Physiotherapy referral form which provider is it intended for?
Provisional diagnosis:
Duration of present condition:
0-3 weeks 3-6 weeks 6-12 weeks 3-6 months 6-12 months 12 months +
Please state the clinical details of present condition including mechanism of injury, major symptoms and history of trauma:
Is the patient currently of work due to this condition?YesNo
If yes, how long ago did they last work?
Any reason patient might be unsuitable for a group education session? E.g. language
YesNoComment
Does the patient have a specific expectation regarding intervention or treatment?
YesNoComment
Referral screening Criteria:
If you feel this referral is appropriate for re-direction onto orthopaedics please consider the CCG Funding Criteria and provide sufficient detail where requested
What conservative management has been trialled? N/A
Physiotherapy Podiatry/Orthotics Weight loss Smoking cessation
Injections Analgesia Walking Aid Splint Other
Please provide detail of conservative management in relation to CBA criteria where appropriate
Deformity: N/A No YesRelevant to Dupuytren’s & Trigger Finger funding policies
Comment:
Has the patient had previous surgery for the current condition?YesNo
Details:
Recent imaging and/or investigations: N/A(Please include any available reports)
X Ray MRI USS Other (Please state)
Blood tests NCS DEXA Other (Please state)
Functional Impairment (e.g. walking distance): (Please select)MinorModerateSevere
Pain Level: (see CBA criteria e.g. Moderate) (Please select)SlightModerateIntenseSevere
If OA Hip/Knee:Oxford Hip score /48Oxford Knee Score /48
(NB: Please ensure you use the new scoring system)
Keele STarT Back Screening Tool (To be completed for all patients with lower back pain)
Patient’s response to the following questions:
Thinking about the last 2 weeks:
  1. My back pain has spread down my leg(s) at some time in the last 2 weeks
  2. I have had pain in the shoulder or neck at some time in the last 2 weeks
  3. I have only walked short distances because of my back pain
  4. In the last 2 weeks I have dressed more slowly than usual because of back pain
  5. It is not really safe for a person with a condition like mine to be physically active
  6. Worrying thoughts have been going through my mind a lot of the time
  7. I feel that my back pain is terrible and it’s never going to get better
  8. In general I have not enjoyed all the things I used to enjoy
  9. Overall, how bothersome has your back pain been in the last 2 weeks?
Not at all 0Slightly 0Moderately 0Very much 1 Extremely 1
Total Score (all 9):Sub score (Q5-9):
© Keele University 01/08/07: Funded by Arthritis Research UK / Disagree
(0) / Agree
(1)
Staff Safety: Are there any further details of which staff should be aware? YesNo
If yes, please give details, e.g. infection risk, mental health or family history
This information is important to ensure staff safety when seeing patients in less supported clinics.