Lower limb reconstruction

Patient's Demographic Details

• Full name (including aliases)
• Date of birth
• Residential and postal address
• Telephone contact number/s – home, mobile and alternative
• Medicare number (where eligible)
• Name of the parent or caregiver (if appropriate)
• Preferred language and interpreter requirements
• Identifies as Aboriginal and/or Torres Strait Islander

Referring Practitioner Details

• Full name
• Full address
• Contact details – telephone, fax, email
• Provider number
• Date of referral
• Signature

Relevant clinical information about the condition

• Presenting symptoms (evolution and duration)
• Physical findings
• Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
• Body mass index (BMI)
• Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
• Current medications and dosages
• Drug allergies
• Alcohol, tobacco and other drugs use

Reason for request

• To establish a diagnosis
• For treatment or intervention
• For advice and management
• For specialist to take over management
• Reassurance for GP/second opinion
• For a specified test/investigation the GP can't order, or the patient can't afford or access
• Reassurance for the patient/family
• For other reason (e.g. rapidly accelerating disease progression)
• Clinical judgement indicates a referral for specialist review is necessary

Clinical modifiers

• Impact on employment
• Impact on education
• Impact on home
• Impact on activities of daily living
• Impact on ability to care for others
• Impact on personal frailty or safety
• Identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

• Willingness to have surgery (where surgery is a likely intervention)
• Choice to be treated as a public or private patient
• Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)

• Please note that where appropriate and available, the referral may be streamed to an associated public allied health and/or nursing service. This may include initial assessment and management by associated public allied health and/or nursing, which may either expedite or negate the need to see the public medical specialist.
• A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.
• Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.