NICE Guidance. Suspected Cancer in Adults COLORECTAL (2WW)

Transcription

1 NICE Guidance Suspected Cancer in Adults COLORECTAL (2WW) Date of Referral: Short date letter merged Name: Full Name DOB: Date of Birth NHS No NHS Number Attach this form to the e-referral within 24 hours If ERS not available, please send this form AND Referral header sheet by secure or FAX The Patient has been informed that this is an urgent referral for suspected cancer The patient is available and willing to attend hospital for tests/appointment within 14 days The patient has been given the 2WW Patient Information Leaflet Hyperlinks to: NICE GUIDANCE 2WW Patient Information Leaflet Please tell your patient they may be offered direct to test colonoscopy/ct colonoscopy unless you choose the clinic option below. Please check performance status/fitness assessment /clinical judgement before selecting option. Blood tests within 2 months of referral are required to arrange direct to test. Failure to provide these may result in the referral being returned and may incur a delay for your patient. All Ages 2WW COLONOSCOPY for any of the following: Abdominal or rectal mass consistent with colorectal cancer (please give details below) Tests show occult blood in faeces (when test is available) Rectal bleeding in association with unexplained abdominal pain or change in bowel habit or weight loss or Iron Deficiency anaemia (HB < 13g /dl for men or <12g/dl for women AND low MCV or low ferritin) (Coeliac status and urinalysis are required before referral for iron deficiency. Coeliac test Yes No ttg (IgA) result: Tissue transglutaminase IgA EMA (IgA) result: Endomysial antibody IgA Age >40 In addition to the above you may also refer Unexplained weight loss with abdominal pain Age >50 In addition to all of the above you may also refer Unexplained rectal bleeding as only symptom Tests show occult blood in faeces (where test is available) Age 60+ in addition to all the above you may also refer Change in bowel habit (CHECK Ca125 in women) Iron deficiency Anaemia (UGIE will also be offered) Test show occult blood in faeces 2WW CLINIC for any of the following: Criteria for 2WW referral but not fit for direct access colonoscopy (see below for guidance) Patient choice for clinic before investigations Any Age Unexplained anal mass, or unexplained anal ulceration Offer qfit (Faecal immunochemical test) for occult blood in faeces to people without rectal bleeding who have unexplained abdominal symptoms who do not meet the criteria for 2WW referral. Page 1 of 5

2 Performance Status Title Given Name Surname Date of Birth NHS Number If in doubt about the referral route or you have a clinical concern, please contact your preferred referral site to discuss with a member of the colorectal team. Reason for Referral -Compulsory The clinical information is essential to the safe and appropriate care of your patient Previous Colonoscopy? YES NO If yes, date of test: Recordings below of colonoscopy result/s in last 3 years : Colonoscopy normal... Weight: O/E - weight O/E - weight O/E - weight Patient Fitness: Information essential to arrange direct to test investigation in secondary care NB: If patient wanting sedation, they must be able to organise escort home and observation overnight Is patient able to give informed consent? (e.g. short term memory loss): YES NO 0 Fully active 1 Cannot carry out heavy physical work 2 Up and about more than half the day and can look after yourself 3 In bed or sitting in a chair for more than half the day and need help in looking after yourself 4 In bed or a chair all the time and need a lot of looking after DIRECT TO TEST OUT PATIENT CLINIC Description Y N Description Y N Anticoagulants including NOACs Antiplatelet e.g. Clopidogrel, prasugrel Metformin Insulin/Sulfonylureas Page 2 of 5

3 Cardiac: Poorly controlled Angina/MI within 3 months Prosthetic valve replacement, previous SBE or vascular graft within one year Diabetes : History of IHD, Diabetes and CKD NB: Recording/s below only displays the latest recording for IHD, Diabetes, CKD Full list is displayed in PMH : Ischaemic heart disease... Blood Test Result in the last TWO months - ESSENTIAL to triage patients direct to test LFTs Bilirubin Alkaline Phosphatase ALT Gamma GT Albumin Result within 2 month REQUIRED Serum bilirubin Serum bilirubin Serum alkaline Serum alkaline phosphatase phosphatase amino amino Serum bilirubin Serum alkaline phosphatase amino Serum bilirubin Serum alkaline phosphatase amino FBC/Ferritin WCC MCV Platelets Ferritin Result within 2 month REQUIRED Total white cell count Mean corpuscular volume (MCV) INR INR Result within 2 months REQUIRED normalised ratio normalised ratio normalised ratio normalised ratio U&Es Sodium Result within 2 months REQUIRED Page 3 of 5

4 Potassium Urea Level Creatinine HbA1c Serum urea A1c - IFCC standardised Serum urea A1c egfr result within 2 month REQUIRED egfr using creatinine (CKD- EPI) per 1.73 square metres... egfr latest result egfr using creatinine (CKD- EPI) per 1.73 square metres... Coeliac s ttg (IgA) Tissue transglutaminase IgA EMA (IgA) Endomysial antibody IgA Serum urea A1c Tissue transglutaminase IgA Endomysial antibody IgA Serum urea A1c egfr using creatinine (CKD-EPI) per 1.73 egfr using creatinine (CKD-EPI) per 1.73 Incomplete information may delay appropriate care for your patient Page 4 of 5

5 Referrer details Name of Referrer: Referring User Organisation Name Organisation Full Address (single line) Usual GP: Usual GP Full Name Name of GP to address correspondence to, if different to accountable GP: Surgery Tel No: Organisation Telephone Number Surgery Organisation Address Surgery Fax: Organisation Fax Number Date of Referral: Short date letter merged Patient details Name: Full Name Address: Home Full Address (stacked) Gender: DOB and Age NHS number: Patient Contacts Contact Consent: Ethnicity: Gender(full) Date of Birth Age: Age NHS Number Home: Patient Home Telephone Mobile: Patient Mobile Telephone Work: Patient Work Telephone Patient Address Carer/Advocate: The patient has confirmed the following person should be included in correspondence Name: Contact Details: Can leave message on answer machine Can contact by text Can contact by Ethnic Origin Interpreter: Yes Language: Main spoken language Wheelchair access Deaf Deafness Accessibility Needs: Risks: NB: Not all services use Texts or s as a method of communication. Registered Blind Registered blind Learning Disability On learning disability register [X]Specific developmental disorders of scholastic skills Other disability needing consideration Accompanied by Carer Vulnerable Adult (details below, if any recording in last 3 years) Vulnerable adult Adult no longer vulnerable Failed or difficult intubation Other: Other: Military veteran Left military service History relating to military service Occupation history Has a carer Is no longer a carer Is a carer Carer Accessible Information Communication Support: Uses a legal advocate... Professional required: Interpreter needed - British Sign Language... Contact method: Requires contact by telephone... Information format: Requires information verbally... If you have any problem with this form or suggested changes, please control & click here to open direct . (NB: NOT TO BE USED FOR REFERRING A PATIENT) 2WW NCA Lower GI Referral Form EMIS Web V2 Gateshead April 2018 To be completed by the Data Team (Insert Dates) Received: / / First Appointment booked: / / First Appointment date: / / 1 st seen: / / Specify reason if not seen on 1 st appointment: Diagnosis: Malignant Benign Page 5 of 5