Lung Form - SOUTH WEST LONDON CANCER NETWORK_ Lung Cancer Referral by malj


									                            SOUTH WEST LONDON CANCER NETWORK                                Suspected Lung Cancer Referral Form (NICE 2006)

                                                                   Date of GP decision to refer:                   No. of pages faxed:
         Urgent Referrals Criteria
           (Please tick category)
                                                                                                              GP DETAILS
Urgent Referral for a Chest X-ray:
                                                                   GP name and initials:                            GP Practice Code:
         Haemoptysis                                      
                                                                   Address:                                         Post Code:
         Unexplained changes in existing symptoms in
          patients with chronic respiratory problems, or
          new persistent problems (more than 3 weeks)      
Cough; Chest or shoulder pain; Dyspnoea; Weight loss;              Telephone No:                                    Fax. No:
Chest signs; Hoarseness; Finger clubbing
Features suggesting a metastasis from the lung;
Persistent cervical or supraclavicular lymphadenopathy;

Urgent Suspected Cancer 2 week wait faxed referral                                                         PATIENT DETAILS
to Cancer Office - any of the following:
                                                                   Last Name:                                      First Name:
LG 1 Chest x-ray suggestive or suspicious of lung
cancer                                                     
                                                                   Address:                                        Post Code:
LG 2 Persistent haemoptysis in smokers/ex-smokers
over 40 years of age                                       
LG 3 Signs of superior vena caval obstruction              
LG 4       Stridor (consider emergency referral for               Daytime Tel or Mobile:                          Gender:         M       F   
                                                                   Date of Birth:                                  Age:
X-ray Result - must be attached
  Abnormal                   
  Attached                   
                                                                   Interpreter required?    Y/N                    Language:                Ethnicity:
NB If the chest x-ray is normal and the GP is still
concerned or suspicious then an urgent referral                    Hospital No:                                    NHS No:
should be made.

                                                                                             COMMENTS/OTHER REASONS FOR URGENT REFERRAL
                              Patient Awareness Questions:

1. Has the patient been made aware of the nature of their referral? Yes    No 
2. Has the patient been supplied with supportive information
about the Urgent Suspected Cancer referral process?                 Yes    No 
3. Have you asked the patient if they will be available
to attend an appointment within the next two weeks?                 Yes    No 
4. Has the patient indicated to you that they
would be available to attend an appointment within the              Yes    No 
next two weeks?

                                                                                                                                                         April 2006
                How to make urgent referrals for suspected lung cancers

Please FAX this form to the Cancer Office at the relevant hospital, with or without an accompanying
letter. You should receive acknowledgement by fax that your referral has been received. Please
ensure that the referral reaches the hospital within 24 hours of the GP’s decision to refer.

        Epsom and St Helier NHS Trust                      Epsom and St Helier NHS Trust

           Epsom General Hospital                               St Helier Hospital
            Dorking Road, Epsom                              Wrythe Lane, Carshalton
             Surrey KT18 7EG                                    Surrey SM5 1AA

FAX:                     020 8296 2741           FAX:                      020 8296 2741

TEL:                     020 8296 2742           TEL:                      020 8296 2742

         Mayday Healthcare NHS Trust                      St George’s Healthcare NHS Trust

        Mayday University Hospital                             St George’s Hospital
       London Road, Thornton Heath                           Blackshaw Road, Tooting
            Croydon CR7 7YE                                     London SW17 0QT

FAX:                        020 8401 3337        FAX:                         020 8725 0778

TEL:                        020 8401 3986        TEL:                         020 8725 1111


          Kingston Hospital NHS Trust                       Kingston Hospital NHS Trust

             Kingston Hospital                                Queen Mary’s Hospital
              Galsworthy Road                                  Roehampton Lane
             Kingston KT2 7QB                                  London SW15 5PN

FAX:                        020 8934 3306        FAX:                         020 8934 3306

TEL:                        020 8934 3305        TEL:                         020 8934 3305

                                                                                                      April 2006

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