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.

• Suspected strangulated/incarcerated or obstruction of any hernia
• Acute, severe abdominal pain with or without associated sepsis
• New onset of obstructive jaundice
• Acute painful perianal conditions
• Acute cholecystitis
• Gallstones with symptoms of cholangitis
• Acute pancreatitis
• Bowel obstruction
• Severe per rectum bleeding
• Acute abscess at any site
• Acute testicular pain

• Refer to HealthPathways or local guidelines
• Lifestyle modification (increased activity, dietary, weight, smoking, alcohol)
• Referral is not mandatory for patient with asymptomatic gallstones or gall bladder polyps on ultrasound if < 10mm
• Short attacks of biliary colic can be managed symptomatically
• Gallstones, points for concern:
  • increasing frequency and severity of pain
  • documented jaundice or deranged LFTs
  • USS evidence of duct dilatation
• If known to have common bile duct stones refer as Cat 1
• If obstructive jaundice and fever - refer to emergency

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)Standard Referral Information
• 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