Anaemia

• Severe anaemia (Hb <80g/L) with risk of cardiovascular and/or syncopal collapse
• Anaemia associated with definite clinical features of overt gastrointestinal bleeding
• Severe cytopaenias if patient is unwell (ie infection, symptomatic anaemia, active bleeding)
  • Eutropenia i.e., < 0.5 x 109/L
  • Haemoglobin < 80 g/L
  • Platelets < 20 x 109/L

Complex or undifferentiated medical problems

• Any sudden decompensation in clinical condition that carries risk of serious adverse events or death
• Pyrexia of unknown origin with temp ≥ 39ºC
• Pyrexia with neutropaenia
• Delirium
• Suspected systemic vasculitis associated with symptoms, signs or investigation results suggestive of vital organ involvement
• Suspected temporal arteritis (giant cell arteritis) with markedly elevated ESR (>100) and/or jaw claudication and/or visual disturbance

Complex paediatric patients transitioning to adult services

• Any sudden decompensation in clinical condition that carries risk of serious adverse events or death

Medication review / poly-pharmacy

• Anaphylactic or other serious adverse drug event
• Markedly prolonged heart rate adjusted QT interval which may herald pro-arrhythmic event
• Marked drug induced electrolyte abnormality (Na <120, K <3.0 or >6.0, corrected Ca >3.0, Mg <0.4)

Osteoarthritis, gout and joint pain

• Acute non-traumatic monoarthritis causing severe pain and/or incapacitating loss of function and/or marked constitutional symptoms
• Suspected septic arthritis

States of altered neurological function

• Witnessed tonic-clonic (grand mal) seizures
• Suspected transient ischaemic attack or stroke on the basis of focal neurological deficits
• Delirium or acute confusional state
• Severe headache or altered level of consciousness of sudden onset

Syncope / pre-syncope

• Syncope / pre-syncope with any of the following concerning features
  • exertional onset
  • chest pain
  • persistent symptomatic hypotension (systolic BP < 90mmHg)
  • severe persistent headache
  • focal neurological deficits
  • preceded by palpitations
  • associated significant physical injury (e.g. fractures, extreme soft tissue trauma, intracranial bleeds) or causing motor vehicle accident
  • family history of sudden cardiac death

Unintentional weight loss

• Uncontrolled hyperthyroidism with risk of thyroid storm
• Vomiting, dysphagia or odynophagia suggesting oesophageal or gastric outlet obstruction
• Associated severe electrolyte abnormalities (K+ <3.0 mmol/L, corrected Ca+ <1.6 or >3.0 mmol/L, Mg+ <0.4 mmol/L, PO4- <0.4mmol/L)

Wounds of uncertain cause or non-healing ulcers

• Severe cellulitis with ongoing or worsening systemic symptoms or fevers despite oral antibiotics for 48 hours
• Foot ulcer in diabetic patient that is not responding to oral antibiotics and regular wound cleaning
• Any infected ulcer associated with systemic inflammatory response symptoms (SIRS) or excessive pain or features suggestive of abscess formation, osteomyelitis or deep tissue infection (necrotising fasciitis)
• Acute Charcot arthropathy
• Ulcers or wounds in a limb with markedly compromised circulation

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

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
• All conservative options that have been pursued unsuccessfully prior to referral
• 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
• Any special care requirements where relevant (e.g tracheostomy in place, oxygen required)
• Current medications and dosages
• Drug allergies
• Alcohol, tobacco and other drugs use

Patient's Demographic Details

• Full name (including aliases)
• Date and country of birth
• Residential and postal address including whether patient resides at an aged care facility
• Telephone contact number/s – home, mobile and alternative
• Medicare number (where eligible)
• Name of the parent or caregiver (if appropriate)
• Name of delegate and contact details (Department of Corrective Services)
• Preferred language and interpreter requirements
• Identifies as Aboriginal and/or Torres Strait Islander
• Any special needs, access requirements and/or disability relevant to the referral

Referring Practitioner Details

• Full name
• Full address
• Contact details – telephone, fax, email
• Provider number
• Date of referral
• Signature
• Nominated general practitioner’s details (if known), if the nominated general practitioner is different from the referring practitioner

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.)