NHS CONFIDENTIAL
OFFICIAL – SENSITIVE: PERSONAL
APPOINTMENT:
WEST CUMBRIA
COMMUNITY RESPIRATORY 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:
CATEGORY: NHS
OFFICE:
CAT II
PP
MAIN CARER & RELATIONSHIP:
CARER CONTACT DETAILS (if different from patient):
Carer Address:
Carer Telephone:
PHONE:
INFECTION RISK? (if yes, state MRSA, etc.)
Home: Patient Home Telephone
YES
NO
Mobile: Patient Mobile Telephone
*CONSENT: Patient has given verbal consent for Community Respiratory Team to
Work: Patient Work Telephone
access GP shared records and to leave an answerphone message
YES
NO
INTERPRETER REQUIRED?
MOBILITY:
(if yes, state language)
Housebound
Walking
Chair
On Ambulatory Oxygen
YES
NO
Unable to transfer onto couch without assistance
ADDITIONAL NEEDS / INFO?
Risk to lone worker (e.g. history of violence or aggression)? Please give details:
Significant communication problems? Please give details:
Other:
*CONFIRMED RESPIRATORY DIAGNOSIS (indicate severity of disease, if known):
*REASON FOR REFERRAL (tick whichever apply):
Pulmonary Rehabilitation Exercise and Education programme (*please consider excluding criteria below)
Assessment & Optimisation (new diagnosis, symptom management and disease management review)
Please indicate symptoms, if applicable:
Cough
Secretions
Breathlessness
Fatigue
Anxiety associated with chronic lung condition
Hospital Discharge Follow-up of respiratory management
Physiotherapy (for patients requiring breathing control, chest clearance techniques) – only available for patients with a
confirmed respiratory diagnosis
Ambulatory Oxygen Assessment
If SpO2 is consistently <93% at rest during a period of clinical stability refer directly to secondary care for LTOT assessment.
Patient can be simultaneously referred to Community Respiratory Team for management support.
ADDITIONAL INFORMATION:
Title Surname
DOB: Date of Birth NHS No: NHS Number
Page 1 of 3
Sender – GP Practice (Printed 08/02/2016); Receiver – Community Respiratory Team
Community Respiratory Service – West Cumbria v1.0 (Nov15)
NHS CONFIDENTIAL
OFFICIAL – SENSITIVE: PERSONAL
PULMONARY REHABILITATION CRITERIA (before referring to Pulmonary Rehabilitation, please check the following):

The patient has been informed about Pulmonary Rehabilitation, understands what is involved and is motivated to
complete the programme
 The patient does not have significant cognitive or physical impairment likely to impair participation in an exercise and
education programme
 The patient (if current smoker) has been encouraged to stop smoking and offered support by the practice including
referral to smoking cessation service as required (N.B. smokers are NOT excluded from the programme)
 The patient is medically safe to exercise:
o No unstable cardiovascular disease (e.g. no unstable angina, no moderate/severe aortic stenosis,
no MI in the last 6 weeks, no acute LVF, no uncontrolled cardiac arrhythmias).
Aneurysm is a relative contraindication, depending on size and location – discuss with team if unsure.
o No uncontrolled hypertension, unstable diabetes or unstable epilepsy
THE PATIENT MEETS ALL THE PULMONARY REHAB REFERRAL CRITERIA
*HISTORY:
Severity of breathlessness symptoms (MRC Dyspnoea Score):
Class 1 (Not troubled except by strenuous activity)
Class 2 (SOB hurrying on level or up hills)
Class 3 (Walks slower than contemporaries due to SOB or stops for breath walking at own pace)
Class 4 (Stops for breath after 100m or few mins on level)
Class 5 (Too breathless to leave house or SOB when dressing / undressing)
Number of exacerbations in the last year: Single Code Entry: Number of COPD exacerbations in past year
Date of last exacerbation: Single Code Entry: Number of COPD exacerbations in past year
Number of hospital admissions for respiratory disease in the last year:
Date of last admission:
Date of last COPD review: Single Code Entry: Chronic obstructive pulmonary disease annual review...
Smoking
MOST RECENT OBSERVATIONS (including date):
BMI: Single Code Entry: Body mass index
OXYGEN SATS AT REST: Single Code Entry: Blood oxygen saturation at rest...
OXYGEN SATS ON EXERTION: Single Code Entry: Peripheral bld ox saturation on supplemental ox on exertion...
BP: Single Code Entry: O/E - blood pressure reading
PULSE RATE: Single Code Entry: O/E - pulse rate
PULSE RHYTHM: Single Code Entry: O/E - pulse rhythm
INVESTIGATIONS (please ensure that the following have been performed within the last 12 months):








Smoking cessation encouraged and support offered at every opportunity
Diagnosis confirmed and recent spirometry performed (include report if results not Read-coded below):
Single Code Entry: Patient unable to perform spirometry...
Recent Full Blood Count
Chest X-ray (on diagnosis or as indicated in the last 2 years)
ECG where clinically indicated
Inhaler technique and medication review completed and optimised
Exacerbation self-management plan arranged, as appropriate
CAT (COPD Assessment Tool) performed. Please note the score:
Title Surname
DOB: Date of Birth NHS No: NHS Number
Page 2 of 3
Sender – GP Practice (Printed 08/02/2016); Receiver – Community Respiratory Team
Community Respiratory Service – West Cumbria v1.0 (Nov15)
NHS CONFIDENTIAL
OFFICIAL – SENSITIVE: PERSONAL
REFERRER DETAILS:
REFFERER’S NAME: Current User
SIGNATURE:
DATE: Short date letter merged
SEND REQUEST TO:
West Cumbria Community Respiratory Team (refer by telephone, fax or post)
Workington Community Hospital, Park Lane, Workington CA14 2RW
N.B. Patients must be registered with a GP in either

Copeland Locality (heart failure rehabilitation is also provided by the West Respiratory Team
in Copeland only)

Allerdale Locality – Workington, Maryport, Cockermouth

Keswick patients – pulmonary rehab and ambulatory oxygen assessment and review only
Title Surname
DOB: Date of Birth NHS No: NHS Number
Page 3 of 3
Sender – GP Practice (Printed 08/02/2016); Receiver – Community Respiratory Team
Telephone
01900 705041
Fax
TBC
Community Respiratory Service – West Cumbria v1.0 (Nov15)