GP ProformaOxfordshire / CRG approved February 2015
Please email to (or fax to 01865 740 409)
This service is entirelyseparate from the 2 week wait service for cancers
For email advice, please OT the address above
Patient’s details / Patient’s background and cultureSurname: / Ethnicity:
Forename: / 1st language:
Known As: / Interpreter required? Y N
DOB:
Sex / GP details
Title / Referring GP:
Pt Address
Postcode: / GP address:
GP Tel no:
NHS No / GP Fax no:
Hospital No / GP Email
Home tel / Date of ref
Work tel / Date ref received
Mobile tel
Please indicate patient’s preferred contact number: / Home Work Mobile
Pre-Referral planning and preparation
For full guidance please refer to:
All patients / A physical examination, CXR if appropriate, blood tests and urinalysis
Recent ECG must be attached
Role of BNP testing
(See guidance) / BNP is justified in patients who do not meet urgent referral criteria but in whom heart failure is still suspected due to breathlessness and other clinical features.
Ankle swelling alone is not an indication for testing. / <29pmol/L / virtually rules out heart failure
29-116pmol/L / raised – HF possible
>116pmol/L / marker of poor prognosis
As of February 2015, all Heart Failure referrals will be triaged on receipt – please assist by completing the triage criteria overleaf, and indicating if you have a specific preference for who assesses the patient. Patients may be seen in secondary care or in a community clinic.
From either location you should receive management advice necessary to fulfil the NICE requirement that all newly diagnosed patients receive specialist input.
Urgency Criteria for the triaging clinicianLast Known Data / Urgent Referrals
(within 2 weeks) / Routine referrals
(within 6 weeks)
Previous documented myocardial infarction? / Yes / No
Co existent angina? / Yes / No
Creatinine > 200 µmol/l / Yes / No
Known moderate or severe valvular heart disease? / Yes / No
New onset fast atrial fibrillation
or flutter (rate >120/min) ? / Yes / No
Is a hospital admission considered imminent? / Yes / No
BNP value / >116pmol/L / <116 pmol/L
Service Preference
Please Indicate Preference / Secondary care cardiologist service / Recommended for those patients who may be candidates for valve surgery, coronary revascularisation, cardioversion or ablation therapy, unstable patients potentially requiring admission to hospital
GP with specialist interest community clinic / Ideal for frail patients, reluctant to travel and if unlikely to need secondary care involvement
Reason for Referral
please complete with details of the patient's presentation and your concerns
Biological data that are valuable
for triage and assessment (not mandatory)
Automatic Data / Manual Data Entry
(if automatic data not available)
Heart Rate
Blood Pressure / «PATIENT_BP»
Pulse Character
Pulse Rhythm
Heart Sounds
Respiratory Rate
Chest signs (past 2m)
Pulse Oximetry
Peripheral Perfusion
JVP (past 2m)
Ankle Oedema
Last eGFR
Sodium
Potassium
Urea
Creatinine
ALT
TSH
Total Cholesterol / «PATIENT_Total_Cholesterol»
HDL
Total Cholesterol:HDL ratio
LDL
Triglycerides
Glucose
HbA1c
Urinalysis findings
(past 2m)
Last CXR
Ever had Spirometry?
«PROBLEMS»
«CURRENT_CONSULTATION»
«REPEATS»
«DRUG_ALLERGY»
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