Grampians
Health	
GH SMART Referral
Referral date: <<Miscellaneous:Date (long)>>
Referral time: <<Miscellaneous:Time>>	
Version 10
(06-21-MD)	

REFERRED BY:

Name: <<Doctor:Name>>
Practice: <<Practice:Name>>
Address: <<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
Provider #: <<Doctor:Provider Number>>

	PATIENT DETAILS:

Name: <<Patient Demographics:Full Name>>
Gender: <<Patient Demographics:Sex>> 
DOB: <<Patient Demographics:DOB (long)>>
Address: <<Patient Demographics:Full Address>>
Home ph: <<Patient Demographics:Phone (Home)>>
Mobile: <<Patient Demographics:Phone (Mobile)>>
Medicare #: <<Patient Demographics:Medicare Number>> Health Fund: <<Patient Demographics:Health Insurance>>
Pension: <<Patient Demographics:Pension Number>>
DVA #: <<Patient Demographics:DVA Number>>
ATSI: <<Aboriginal or Torres Strait Islander>>
<<Patient Demographics:Ethnicity>>
Interpreter required: <<Interpreter required?>>
Next of Kin: <<Patient Demographics:Next of Kin>>
<<Patient Demographics:Next of Kin Relationship>>
<<Patient Demographics:Next of Kin Phone>>
	
PATIENT CONSENT:

Patient consents to attend MBS bulk billed clinic if available: <<Patient consents to MBS bulk billed clinic if avail?>>
If yes, do you wish this to be an indefinite referral? <<If yes, do you wish this to be an indefinite referral?>> 
Patient consents to sharing medical information: <<Patient consents to sharing of medical information>>
	
SPECIALTY SERVICE: <<Specialist clinic - MANDATORY>>
	
REFERRAL DETAILS:

Reason for referral: <<Reason for Referral>>
GP Advised Priority: <<GP Advised Priority>>
Reasons for repeat referral/change in condition: <<If change in condition provide further info for triage>>
Are you the patient's usual GP: <<Are you the patient's usual GP>>
If not, who is the usual GP:<<If not, list name of usual GP & Practice>>
	SPECIAL ALERTS:

Cancer status: <<Cancer status for triage>>
Positive FOB: <<Is this for positive FOB?>>
NBCSP reference number: <<If yes, NBCSP ref req & attach results- req for triage>>
Smoking status: <<Is patient a smoker>>
Any disability: <<Any disability?>>
Any other disability? <<Other disability?>>
	
ANTENATAL SHARED MATERNITY CARE: <<Is pt for Antenatal Shared Care with GP and BHS?>>

CURRENT PREGNANCY: <<Clinical Details:LNMP>> <<Clinical Details:EDC>>
	
REASON FOR REFERRAL & PROVISIONAL DIAGNOSIS:

<<Detailed history of presenting complaint>> 
	
BLOOD PRESSURE:

<<Current BP >>	WEIGHT:

<<Current weight>>
	
PROGRESS NOTES:

<<Summary:Progress Notes (Selected)>>
	
ALLERGIES:

<<Clinical Details:Allergies>>
	
CURRENT MEDICATIONS: 

<<Clinical Details:Medication List>>

PAST MEDICAL AND SURGICAL HISTORY:

<<Clinical Details:History List>>
	
FAMILY & SOCIAL HISTORY:

<<Clinical Details:Family History>> 
<<Clinical Details:Social History>>
	
TESTS TODAY:

<<Test ordered today:These aren't viewable at triage>>
	
NAME OF PATHOLOGY PROVIDER:

<<Name of Pathology provider>>
	
NAME OF RADIOLOGY PROVIDER:

<<Name of Radiology provider>>
	
INVESTIGATION RESULTS:

<<Summary:Investigation Results (Selected)>>	

Electronic GP signature: <<Doctor:Name>>

Patient Name:<<Patient Demographics:Surname>>, <<Patient Demographics:First Name>> DOB: <<Patient Demographics:DOB>>
Recipient: BHS Date of Report: <<Miscellaneous:Date>>