Supplementary Material

CNS SMDT Meeting Referral Form

1. Please complete and return this form, by e-mail to the SMDT co-ordinator or hand to CNS Lead Nurse within 24hours of the Decision to Refer (DTR) the patient
2. All SMDT referrals must be received no later than 4pm on Tuesday
3. All mandatory fields in bold must be completed for the referral to be processed. Please note, any omissions or incomplete patient information may lead to deferment.
E-mail: (Outside Referrals) Please put ‘cns’ in the subject heading
(Internal Referrals)
Direct Dial: 01223 274427 (Extn 4427) Fax: 01223 274 457
Date of MDT: / Referring Hospital:
Name:
NHS No:
Hospital No:
DOB
Address & post code: / Referring Clinician:
Who is the named designated contact at referring hospital:
Phone & Fax/email:
GP Name, Address & post code:
Patient Tel Contact No:
Where is the patient: / On-call Neurosurgical Consultant:
Back to accepting team? Y / N / On-call SpR:
Y/N / dd/mm/yy / dd/mm/yy
Fast track/ Urgent 2 week wait (62 day pathway) YES or NO? / Decision to Refer by GP / First Seen Date
External Consultant Referral? / Trust Receipt Date Of Referral / Recurrence:
Yes or No?
Has FDT (first definitive treatment) taken place? If so, what was it and where?
Waiting time adjustment? (Reason and days)
Consultant Upgrade? Y/N? If so, when?
18 week information:
Is the patient on an 18 week RTT pathway? YES NO
If YES, is this referral part of an existing pathway or the start of a new pathway?
Continuation of EXISTING pathway Start of a NEW pathway Continuation of a STOPPED pathway
(1st treatment not given) (new condition/new treatment) (1st treatment given)
Is this referral for: Diagnostic Tests only Opinion only
Other organisations in the pathway:
Unique pathway identifier:
(generated with original referral)
Allocated by (code):
(organisation who received original referral) / Latest 18 week
clock start date:
DD / MM / YYYY

(date the patient started on pathway or date of this referral if new pathway) / Date of decision
To onward refer:
DD / MM / YYYY

CNS SMDT Meeting Referral Form

Presenting symptoms / Duration:
Performance Status:
Steroids: Yes / No Dose: Response:
Investigations: / CT / MRI / Mass lesion Y / N / Enhancing Y / N
Contrast given: Y / N
If no, ?reason:
Has staging CT (chest/abdo/pelvis)
been performed? If no, ?reason:
Mass:
L / R / bilateral / Lobe:
Frontal / Parietal / temporal / Occipital / Post fossa
Where are the scans: Link / PACS / Other:
Scans reviewed by: / Neuro-radiologist: Y / N / Neurosurgical Consultant: Y / N
Previous Oncological treatment?
Previous primary site(s):
Previous treatment & treatment dates:
Expected survival:
Other investigations, concurrent illness, date and findings:
Reason for referral to SMDT: New patient / New diagnosis / New symptoms
Review of SMDT decision
Your name: Contact Number:
Radiology Sent: Y/N / Date:
If this patient’s investigations were completed outside Addenbrooke’s, please quote the location: