LAMBETH AND SOUTHWARK – EARLY INFLAMMATORY ARTHRITIS REFERRAL FORM
DATE OF REFERRAL: Short date letter
Patients with suspected EIA will be seen within 3 weeks of referral
merged
Hospital
King’s College Hospital
Guy’s Hospital
Clinic
kch-tr.EarlyInflammatoryArthritisAppointments@nhs.net gst-tr.rheumandlupusreferrals@nhs.net
Referring to: or call Rheumatology SpR on-call (24hr via switchboard)
Section 1
PATIENT INFORMATION
D.O.B.: Date of Birth
GENDER: Gender
SURNAME: Surname
NHS NUMBER: NHS Number
FIRST NAME: Given Name
HOSPITAL NUMBER: Hospital Number
ADDRESS: Temporary Full Address (single line)
FIRST LANGUAGE: Main Language
TELEPHONE NUMBERS
DAYTIME: Patient Work
Telephone
Section 2
Y
/N
TRANSPORT REQUIRED?
Y
/N
HOME: Patient Home Telephone
PRACTICE INFORMATION
PRACTICE ADDRESS:
Organisation National Practice Code
Organisation Full Address (single line)
Section 3
INTERPRETER REQUIRED?
CLINICAL INFORMATION
MOBILE: Patient Mobile Telephone
REFERRING GP:
TELEPHONE NUMBER: Organisation Telephone Number
FAX NUMBER: Organisation Fax Number
Email: Organisation E-mail Address
Please tick relevant referral criteria and indicate involved
joints on the diagram
Please refer any patient with suspected inflammatory
arthritis if any of the following apply:





Swelling in 1 or more joints
Positive MCPJ or MTPJ squeeze test
Small joint of hands and feet or wrists affected
Symptoms for 3 weeks or more
Please mark the affected joints on the diagram
opposite
Date of symptom onset:
Other features/information – continue on separate sheet if
required:
Drag crosses onto the affected joints
Other affected joints:
1
Please attach patient summary sheet.
Section 4 INVESTIGATIONS TO BE ARRANGED AT REFERRED INSTITUTION AT TIME OF REFERRAL.
Please tick box to indicate requested. Do not wait for result before referring.
Full Blood
Renal
Liver
Erythrocyte
C-Reactive
Rheumatoid AntiAntiCount
Function
Function
Sedimentation Protein
Factor (RF)
Citrullinated
nuclear
(FBC)
Tests (U&E) Tests (LFT) Rate (ESR)
(CRP)
peptide (anti- Antibody
CCP)
(ANA)
Section 5 Information to support Early Arthritis referrals
NICE Quality Standards on Rheumatoid Arthritis (QS33):
Quality Statement 1 = ‘People with suspected persistent synovitis affecting the small joints of the hands or feet, or
more than 1 joint, are referred to a rheumatology service within 3 working days of presentation.’
Quality Statement 2 = ‘People with suspected persistent synovitis are assessed in a rheumatology service within 3
weeks of referral.’
Synovitis is characterised by joint pain and joint swelling, although significant swelling may NOT be obvious clinically.
Patients should be referred urgently if any of the following present:
 There is 1 or more joint affected
 The small joints of the hands or feet are affected
 There is a positive MCPJ or MTPJ squeeze
Other features suggestive of inflammatory arthritis include:
 Early morning joint stiffness >30 minutes
 Joint stiffness following periods of immobility
 Constitutional upset, such as loss of appetite, weight loss, fatigue
 The presence of extra-articular features of inflammatory arthritis such as psoriasis, iritis or uveitis, inflammatory
bowel disease
Do not avoid referring urgently any person with suspected persistent inflammatory arthritis whose blood tests show
a normal acute phase response or negative serology (Rheumatoid Factor or Anti-Citrullinated peptide) .
X-rays will usually be carried out following the Rheumatology out-patient clinic consultation, however, please
append the reports of any recent X-rays carried out.
For further information:
GSTT: Early Arthritis Clinic page under Rheumatology Services www.guysandstthomas.nhs.uk
KCH: www.kch.nhs.uk/service/a-z/rheumatology
Please note that LIMS (Lambeth) and MCATS (Southwark) can also make referrals using this form, if appropriate.
Patient’s Medical Summary:
Title Initial Last Name
Problems
Medication
Values and Investigations
2