NHS CONFIDENTIAL
OFFICIAL – SENSITIVE: PERSONAL
APPOINTMENT:
Community Heart Failure Service Primary Care Referral Form
Items Marked with * MUST be completed. INADEQUATELY COMPLETED FORMS WILL BE RETURNED TO THE REFERRER
PATIENT DETAILS:
SURNAME:
DOB:
Surname
Date of Birth
FIRST NAME:
GENDER:
Given Name
Gender
NHS NUMBER:
NHS Number
ADDRESS:
Home Full Address (stacked)
PRACTICE:
Organisation Name
Organisation Full Address
(stacked)
Organisation Telephone
Number
Practice code: Organisation
National Practice Code
URGENCY:
2 weeks
OFFICE:
4 weeks
CATEGORY: NHS
CAT II
PP
MAIN CARER & RELATIONSHIP:
CARER CONTACT DETAILS (if different from patient):
Carer Address:
Carer Telephone:
PHONE:
Home: Patient Home Telephone
Mobile: Patient Mobile Telephone
Work: Patient Work Telephone
INTERPRETER REQUIRED?
(if yes, state language)
YES
NO
CONSENT:
Patient has given verbal consent for Heart Failure team to
YES
NO
access GP record:
Patient has given consent for referral to Heart Failure team:
YES
NO
MOBILITY:
Housebound
Walking
ADVOCATE REQUIRED?
(if yes, state whom)
Wheelchair
On Ambulatory Oxygen
YES
NO
Unable to transfer onto couch without assistance
ADDITIONAL NEEDS / INFO?
Any risk to lone worker (e.g. history of violence or aggression)?
Any significant communication problems?
REFERRAL CRITERIA – Patients must meet ALL criteria for referral to be accepted
Only refer if:
Newly confirmed Left ventricular Systolic Dysfunction (LVSD) or Heart Failure with Preserved Ejection Fraction (HFPEF)
on Echo, MRI Scan or Angiogram AND
Willing to participate (excluding those with severe cognitive impairment) AND
Patients with known LVSD who:
Have previously seen the ‘Heart Failure Nursing Team’ but have become more symptomatic OR
Have not seen the ‘Heart Failure Nursing Team’ and may benefit from education about the condition and its
management
SUSPECTED HEART FAILURE: patient should have confirmation of diagnosis before referral
VALVE DISEASE: patient should have Moderate or Severe valve disease which has contributed to current condition or
admission
Please include latest ECG and Echo report with referral form
THE REFERRAL WILL BE RETURNED IF ECG AND ECHO REPORTS ARE NOT INCLUDED
REASON FOR REFERRAL (tick whichever apply)*
Self-management advice and education
Please utilise heart failure nursing service for patients with more complex needs, not for straightforward medication
titration. If there is a particular problem with medication management/titration, please give details below:
ACE INITIATION
ACE TITRATION
BETA-BLOCKER INITIATION
BETA-BLOCKER TITRATION
DIURETIC MANAGEMENT
Other reason for referral:
Title Surname
DOB: Date of Birth NHS No: NHS Number
Page 1 of 4
Sender – GP Practice (Printed 23/03/2016); Receiver – Community HF Team
Community Heart Failure Service Primary Care Referral v1.0 (Nov15)
NHS CONFIDENTIAL
OFFICIAL – SENSITIVE: PERSONAL
SYMPTOMS*
Breathlessness
Severity of breathlessness symptoms (NYHA):
Class 1 (no limitation to ordinary physical activity)
Class 2 (slight limitation on ordinary physical activity)
Class 3 (moderate limitation on ordinary physical activity)
Class 4 (symptoms at rest or minimal exertion)
Orthopnoea
PND
Cough
Chest pain
Palpitations
Fatigue
Peripheral Oedema:
Dizziness
None
Mild – resolves with rest
Moderate – mid calf/ below knee
Severe – above knee
Severe – thigh/ sacral/abdomen
Other
PAST MEDICAL HISTORY AND RISK FACTORS*
ISCHAEMIC HEART DISEASE:
Single Code Entry: Ischaemic heart disease
PREVIOUS MI:
Single Code Entry: Acute myocardial infarction...
ATRIAL FIBRILLATION or FLUTTER:
Single Code Entry: Atrial fibrillation and flutter...
HEART VALVE DISEASE:: Valves of heart and adjacent structures operations...
PACEMAKER or ICD:
Single Code Entry: [V]Cardiac pacemaker in situ...
HYPERTENSION:
Single Code Entry: Hypertensive disease
DIABETES:
Single Code Entry: Diabetes mellitus
HYPERLIPIDAEMIA:
Single Code Entry: Disorders of lipoid metabolism
STROKE/CEREBROVASCULAR DISEASE:
Single Code Entry: Cerebrovascular disease...
PERIPHERAL VASCULAR DISEASE:
Single Code Entry: Other peripheral vascular disease
ASTHMA or COPD:
Single Code Entry: Chronic obstructive pulmonary disease
CKD 3-5:
Single Code Entry: Chronic kidney disease stage 3...
Smoking
Alcohol Consumption
Title Surname
DOB: Date of Birth NHS No: NHS Number
Page 2 of 4
Sender – GP Practice (Printed 23/03/2016); Receiver – Community HF Team
Community Heart Failure Service Primary Care Referral v1.0 (Nov15)
NHS CONFIDENTIAL
OFFICIAL – SENSITIVE: PERSONAL
EXAMINATION*
Blood Pressure
Postural BP if recorded:
Single Code Entry: Sitting blood pressure reading...
Single Code Entry: Lying systolic blood pressure...
Single Code Entry: Standing systolic blood pressure...
PULSE RATE / RHYTHM:: O/E - pulse rate...
Weight
INVESTIGATIONS
NT-BNP:
Single Code Entry: Plasma N-terminal pro B-type natriuretic peptide conc...
HAEMOGLOBIN ESTIMATION:
Single Code Entry: Haemoglobin estimation
HbA1c:
Single Code Entry: HbA1c level (DCCT aligned)...
Urea & Electrolytes: Urea and electrolytes...
GFR:
Single Code Entry: GFR calculated abbreviated MDRD...
LFTs: Liver function test
TFTs: Thyroid hormone tests
ECG (enclosed if available):: Electrocardiography
ECHOCARDIOGRAM:
Single Code Entry: Echocardiogram...
CHEST X-RAY:
Single Code Entry: Standard chest X-ray
Medication
Allergies
Previous cardiac medication intolerances (if not specified in allergies): Free Text Prompt
REFERRER DETAILS:
REFFERER’S NAME: Current User
SIGNATURE:
DATE: Short date letter merged
SEND REQUEST TO:
North Cumbria Heart Failure Service, Wigton Hospital Cross Lane, Wigton CA7 9DD
Trudy Edgar (team lead)
Wendy Wardle
Judith Easton
Nicola Todd
South Lakes Community Heart Failure Service, 1 Weavers Court, Westmorland
General Hospital, Burton Road, Kendal LA9 7GL (Simon Morehead, HF Specialist Nurse)
Preferred location for seeing patient:
Garburn House, Kendal
Title Surname
DOB: Date of Birth NHS No: NHS Number
Page 3 of 4
Sender – GP Practice (Printed 23/03/2016); Receiver – Community HF Team
GP surgery
Tel: 016973 66637
Fax: 016973 66638
Mob: 07825 681099
Mob: 07990 506384
Mob: 07768 487230
Mob: 07769 961245
Tel 01539 716672
Fax 01539 716671
Domiciliary visit
Community Heart Failure Service Primary Care Referral v1.0 (Nov15)
NHS CONFIDENTIAL
OFFICIAL – SENSITIVE: PERSONAL
BHF Heart Failure Nurse Practitioners, 2 Fairfield Lane, Barrow in Furness LA13 9AH
(Anna Pearce, Lindsay Cragg & Helen Fawcett - heartfailureteam@cumbria.nhs.uk)
Tel 01229 402575
Fax 01229 402569
Preferred location for seeing patient:
102 Dalton Lane , Barrow in Furness
Ulverston Health Centre
Dalton Health Centre
Grange Clinic
Title Surname
DOB: Date of Birth NHS No: NHS Number
Page 4 of 4
Sender – GP Practice (Printed 23/03/2016); Receiver – Community HF Team
Millom Hospital
Community Heart Failure Service Primary Care Referral v1.0 (Nov15)