• A medical emergency requiring immediate provision of medical care including:
  • Suicidal or immediate danger of self-harm
  • Aggressive behaviour with immediate threatening risk to others
  • Concerns around acute deterioration in function and/or significant loss of previously acquired skills that is suggestive of an underlying neurological deterioration/condition
  • Sudden onset of neurological symptoms (i.e., sudden weakness, slurred speech, seizures)
  • Non-verbal child with acute distress and possible acute pain where medical condition needs exclusion, e.g. tooth abscess, bone infections or osteopaenic fractures

Growth concerns

• Faltering growth (failure to thrive in children < 6 years)
  • severe malnutrition
  • temperature instability
  • cardiovascular instability – postural heart rate change
• Short stature
  • possible CNS signs (visual disturbance, morning headaches)
    

Developmental concerns

• Nonverbal child with acute distress and unable to examine adequately for medical conditions causing pain eg tooth abscess, bone infections or osteopaenic fractures

Behavioural concerns

• Suicidal or immediate danger of self-harm
• Aggressive behaviour with immediate threatening risk to vulnerable family members

Irritable Infant

• Fluctuating or altered conscious level – weak cry, not waking appropriately for feeds, lethargy, maternal concern of failure of normal interaction
• Suspicion of harm or any unexplained bruising, especially in infant <3 months
• Significant escalation in frequency or volume of vomiting
• New onset of blood mixed in stool
• Fever
• Increased respiratory effort
• Weak or absent femoral pulses in infant <3 months
• Presence of newly noted heart murmur in infant <3 month

Physical findings od concern in an effort <1 year

• Inguinal hernia that cannot be reduced
• Painless firm neck swelling that is increasing in size.
• White pupil or white instead of red reflex on eye examination.
• Previously unrecognised intersex genitals (ambiguous as either virilised female or incomplete formation male eg bilateral absent testes).
• Possible Infantile Spasms. This may be frequent brief episodes of head bobbing (with or without arm extension) in an infant less than 12 months old.
• Absent femoral pulses.
• Infant <3 months with newly noted murmur and any of the following:
  • poor feeding
  • slow weight gain
  • weak or absent femoral pulses
  • post ductal (foot) oxygen saturation < 95%
  • respiratory signs (wheeze, recession or tachypnoea)

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.)