REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
ORTHOPAEDIC CLINIC
Template for correspondence about patient with
FRACTURES OF UPPER AND LOWER LIMBS (EXCLUDING ACUTE AND EMERGENCY ISSUES)

SEND TO Dr Donald Pitchford (Director of Orthopaedics)
Outpatient Access and Scheduling Centre
Fax: 07 5687 4497                            OR

Secure transmission service via Medical Objects or
Healthlink to
QHEALTH,GOLD COAST HEALTH Outpatients
Outpatient Bookings and Referrals	FROM <<Doctor:Name>>
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
Email: <<Doctor:E-mail>>
Provider Number: <<Doctor:Provider Number>>

<<Miscellaneous:Date (long)>>

Dear Dr Pitchford,

SECTION 1 Patient details

RE: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>
AGE: <<Patient Demographics:Age>>

Gender: <<Patient Demographics:Gender>>
Address: <<Patient Demographics:Full Address>>
Home Ph: <<Patient Demographics:Phone (Home)>>
Mobile Ph: <<Patient Demographics:Phone (Mobile)>>
Medicare Number*: <<Patient Demographics:Medicare Number>>(*Medicare ineligible patients will incur a consultation fee)
	Next of Kin/Alternative Contact: <<Patient Demographics:Next of Kin>>
Next of Kin/Alternative Contact Ph: <<Patient Demographics:Next of Kin Phone>>
Does patient identify as Aboriginal and/or Torres Strait 
Islander: <<Patient Demographics:ATSI>>
Interpreter required: <<Interpreter required>>
If yes, specify language:  <<If yes specify language>>	

SECTION 2 Reason for referral and additional clinical information

What is the reason for this referral: <<Specify main reason for referral>>

Please provide provisional diagnosis (if available): <<Provisional diagnosis if available>>

Please include any symptoms and date of onset (if known): <<Symptoms and date of onset if known>>

Paste or type relevant history, clinical examination findings and treatment to date if required	

SECTION 3 Mandatory clinical information

Delayed presentation of nerve or tendon injury: <<Delayed presentation of nerve or tendon injury>>
If yes, please specify: <<If yes, specify nerve or tendon injury details>>

Delayed presentation of joint dislocation: <<Delayed presentation of joint dislocation>>
If yes, please specify: <<If yes, specify joint dislocation details>>

Delayed or non-union of a fracture: <<Delayed or non-union of a fracture>>
If yes, please specify: <<If yes, specify delayed or non-union fracture details>>

Mal-union affecting function: <<Mal-union affecting function>>
If yes, please specify: <<If yes, specify mal-union affecting function details>>

SECTION 4 Investigations

Please indicate whether the following pre-requisite investigations have been undertaken in order for this referral to be processed and attach the results. In addition please also attach any investigation results you consider to be relevant.

XR results (patient to bring imaging/films to clinic)

<<Summary:Investigation Results (Selected)>>

SECTION 5 Duration of referral

Please indicate how long you would like your referral to remain valid:<<Duration of referral>>

Indefinite referrals do not expire until the patient has been discharged by the hospital service. When referrals expire, there is an expectation that the referring GP or another GP will review the care of the patient. If the patient still requires specialist care, the GP will then be required to submit a new referral for ongoing care. 

SECTION 6 Social factors and impact on the patient

Consider the impact on employment/education; activities of daily life; ability to care for others; personal safety/frailty; other factors. Please paste or type relevant information.

	

SECTION 7 Medical history including co-morbidities and previous surgical interventions

Alcohol: <<Clinical Details:Alcohol>>
Smoking: <<Clinical Details:Smoking>>

<<Clinical Details:History List>>

<<Operation:CoMorbidities>>

<<Operation:Previous Procedures>>

Allergies: <<Clinical Details:Allergies/Adverse Reactions>>

Current prescribed medications: <<Clinical Details:Medication List>>

SMOs/VMOs in this Specialist Service	

Dr Donald Pitchford (Director)	Dr Matthew Alfredson	Dr Jason Beer	
Professor Randy Bindra	Dr Lochlin Brown	Dr Price Gallie	
Dr Haig Lennox	Dr Simon Platt	Dr James Reidy	
Dr Song Tan	Dr Fraser Taylor	Dr Michael Thomas 	
Dr Francois Tudor			

General information about referrals	

Queensland Clinical Prioritisation Criteria (CPC) are available for this condition and specialty. These criteria can be viewed by visiting: https://cpc.health.qld.gov.au/

Referral Templates that outline clinical information and investigations required to safely refer your patient into Gold Coast Health can be accessed via: https://www.healthygc.com.au/Health-Care-Professionals/Referral-Templates.aspx