Suspected Bladder and Renal Cancer Referral Form

Suspected Bladder and Renal Cancer Referral Form

Referrer Details / Patient Details
Name and Position: / Name:
«PATIENT_Forename1»«PATIENT_Surname» / DOB:«PATIENT_Date_of_Birth»
Address:
«PRACTICE_Name»
«PRACTICE_BlockAddress» / Address:
«PATIENT_BlockAddress» / Gender: «PATIENT_Sex»
Hospital No:
NHS No: «PATIENT_Current_NHS_Number»
Tel No:
«PRACTICE_Main_Comm_No» / Telephone Number: «PATIENT_Main_Comm_No» / «PATIENT_Mobile_No»
Number Confirmed
Practice Safe Haven Email:
Practice.email / Has a carer: Yes No / Capacity concerns? (e.g. has dementia/ learning disability)
Decision to Refer Date:
«SYSTEM_Date» / Translator Required: Yes No Language: Lang_spoke / Mobility:
Clinical details
Please detail your conclusions and what needs excluding or attach referral letter.

Aged 45 and over and have:

unexplained visible haematuria without proven urinary tract infection or

Unexplained’ haematuria refers to patients who do not currently have conditions that can cause haematuria, e.g. urinary stone disease and UTI.

visible haematuria that persists or recurs after successful treatment of a proven urinary tract infection, or

Aged 60 and over and have unexplained non-visible haematuria with dysuria

Unexplained’ haematuria refers to patients who do not currently have conditions that can cause haematuria, e.g. urinary stone disease and UTI.

Dysuria is defined as burning or discomfort in the urethra on voiding.

Menstruating females may have non-visible haematuria for 3 days prior to and 5 days post menstruation. non-visible haematuria may also be present for 3 days post intercourse. Please exclude these prior to referral

Aged 60 and over and have unexplained non-visible haematuria with a raised white cell count on a blood test.

Please provide: FBC (< 8 weeks old)

tableoftests(Hae,pcv,mcv,mchc,plat,rbc,wbc,neut,lymph_no,mono,eosin,baso,esr).(8w)[Full Blood Count & Differential]

Unexplained’ haematuria refers to patients who do not currently have conditions that can cause haematuria, e.g. urinary stone disease and UTI.

A raised WCC is defined as >11 x 109/L

Menstruating females may have non-visible haematuria for 3 days prior to and 5 days post menstruation. non-visible haematuria may also be present for 3 days post intercourse. Please exclude these prior to referral

A soft tissue mass identifiedonimaging thought to arise from the urinary tract.

Please provide: FBC, U&E (including creatinine and eGFR)
(< 8 weeks old)

tableoftests(Hae,pcv,mcv,mchc,plat,rbc,wbc,neut,lymph_no,mono,eosin,baso,esr).(8w)[Full Blood Count & Differential]

tableoftests(ure,cre,sod,pot,gfr,uric).(8w)[Urea & Electrolytes]

This includes solid renal masses, complex renal cysts (i.e. cysts containing septa, calcification or soft tissue elements) and soft tissue bladder masses. This does not include distended bladders of urinary retention.

Smoking status:
smoking#b / WHO Performance Status:
0 -Fully active
1 -Able to carry out light work
2 -Up & about >50% of waking time
3 -Limited to self-care, confined to bed/chair >50%
4 -No self-care, confined to bed/chair 100%
BMI if available:
Weight#fa
Please attach additional clinical issues list from your practice system. Details to include:Current Medication, co-morbidities, significant psychosocial issues, allergies, relevant family history & alcohol status.Please see below.

Medication

active.(t)#fbolh[Repeat Medication]

RxAcute.(3mt)#adif

Problems

Problems.(t)#ab[Known Problems]

Medical History

Priority12.(t)#ab[Significant Medical History P1 and P2]

Allergies

allergy.(t)#aiefg[Known Allergies]

Family History

family_his.(all)(124)

Alcohol Status

Alcohol.(3)#acd

Other

Checklist
The two week wait pathway is a pressured Gloucestershire resource - please continue to help us ensure our patients are seen and investigated in a timely manner. This helps to minimise any anxiety for patients during this uncertain time, to pick up a cancer diagnosis and start treatment earlier, all which improve patient outcomes and experience.
I have informed the patient that their symptoms mean we need to exclude cancer
I have given the patient the 2ww cancer referral information leaflet
I have decided not to inform the patient / give the leaflet (e.g. lack of mental capacity)
If the patient is then unable to attend the 2ww appointment in the next 2 weeks, please delay the referral to a time when they can attend. This allows other patients to be prioritised.
Trust Specific Details
For hospital to completeUBRN:
Received date:

[Suspected Bladder and Renal Cancer] TWW / Feb 2018 / Cancer CPG / Version 1.0 / Review date Feb 2019Page 1 of 3