If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

•  Potentially life threatening symptoms suggestive of:

  • acute upper GI tract bleeding

  • acute severe lower GI tract bleeding

  • oesophageal foreign bodies/food bolus

  • Acute Severe Colitis*

  • bowel obstruction

  • abdominal sepsis

• Severe vomiting and/or diarrhoea with dehydration

• Acute/fulminant liver failure (to be referred to a centre with dedicated hepatology services

• Biliary sepsis (to be referred to a centre with ERCP service)

* Acute severe colitis as defined by the Truelove and Witts criteria – all patients with ≥ 6 bloody bowel motions per 24 hours plus at least one of the following:

• temperature at presentation of > 37.8°C,
• pulse rate at presentation of > 90 bpm,
• haemoglobin at presentation of < 105 gm/l, CRP >20mg/dl at presentation (or ESR > 30 mm/hr)

Consider referring to a dietitian e.g. Fermentable oligo -, di-, mono-saccharides and polyols (FODMAP) diet

Does your patient meet the minimum referral criteria?

If your patient does not meet the minimum referral criteria

• Consider other treatment pathways or an alternative diagnosis
• If you still need to refer your patient:
  • Please explain why (e.g. warning signs or symptoms, clinical modifiers, uncertain about diagnosis, etc.)
  • Please note that your referral may not be accepted or may be redirected to another service

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

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, BMI), 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

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 functioning – low/medium/high
• 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