First Trimester

• Suspected or proven ectopic pregnancy
• Heavy bleeding/severe pain (haemodynamically unstable) +/- fever (suspicion of sepsis)
• Threatened or incomplete miscarriage if haemodynamically unstable
• Intractable vomiting

Post first trimester

• Heavy bleeding/severe pain (haemodynamically unstable) +/- fever (suspicion of sepsis)
• Threatened or incomplete miscarriage
• Threatened preterm labour
• Pre-term rupture of membranes
• Evidence of cervical incompetence
• Intractable vomiting
• Hypertension equal to or greater than 140/90 mm Hg
• Severe headaches or visual disturbances
• Suspected pre-eclampsia presenting with any of the following:
  • uncontrolled severe hypertension (i.e., diastolic blood pressure > 110 mmHg or systolic blood pressure > 170mmHg)
  • neurological complications
  • renal impairment
  • pulmonary oedema
  • thrombocytopaenia
  • If gestational age is 23-32 weeks or fetal weight is less than 1500grams then contact local service as referral for emergency treatment may be directed to a level 6 maternity service for obstetric assessment
• Seizures or fainting
• Acute mental health concern needing to be seen by acute mental health service or psychiatric emergency centre.
• Abdominal trauma – GP check with maternity booking hospital level of care require
• Any concern regarding fetal growth requires confirmation with ultrasound (if available) and referral to maternity service as indicated.
• Change in fetal movement pattern
• Suspected or confirmed fetal death in utero
• Any other significant concern
  

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

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), 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

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)
• 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

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.)