Mirena®/progesterone releasing IUD Insertion or removal, for HMB or HRT
Adult

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Emergency Referrals

Useful Management Information

The local service may require the referring GP to provide a Mirena® prescription for the device to the patient who must bring the device with her to the clinic
Where available for the routine removal or insertion of Mirena®/progesterone releasing IUD please consider referral to True – relationships and reproductive health  (formerly known as Family Planning Queensland) or a Women’s Health specialty primary care provider who may be able to provide this service in their own clinic.

Minimum Referral Criteria

Does your patient meet the minimum referral criteria?

Category 1 (appointment within 30 calendar days)	Heavy Menstrual Bleeding (HMB) with anaemia (Hb<85) or requiring transfusion
Category 2 (appointment within 90 calendar days)	Heavy Menstrual Bleeding (HMB) with anaemia (Hb>85)
Category 3 (appointment within 365 calendar days)	Heavy Menstrual Bleeding (HMB) without anaemia not responding to maximal medical management Contraception (if clinically indicated) HRT Replacement Mirena®/ progesterone-releasing IUD (if clinically indicated) Mirena®/ progesterone-releasing IUD insertion or removal (if clinically indicated) NB: Routine Mirena®/progesterone-releasing IUD insertion for contraception may be out-of-scope for certain Gynaecology services.
If the patient does not meet the criteria for referral but the referring practitioner believes the patient requires specialist review, a clinical override may be requested: Please explain why (e.g. warning signs or symptoms, clinical modifiers, uncertain about diagnosis, etc. Please note that your referral may not be accepted or may be redirected to another service.

Standard Referral Information

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.)

Essential Referral Information

Medical history -relevant family, menstrual, obstetric, contraceptive and brief sexual history or history of STIs
Most recent or current cervical screening
Mirena® prescription (The local service may require the referring GP to provide a prescription for the device to the patient who must bring the device with her to the clinic)

If a specific test result cannot be obtained due to access, financial, religious, cultural or consent reasons a clinical override may be requested. This reason must be clearly articulated in the body of the referral.

Additional Referral Information

BMI
Pelvic USS if lost strings, HMB or other clinical indication
STI screen result – endocervical swab or first catch urine for chlamydia +/- gonorrhoea NAA

Send Referrals To

Smart Referrals

Preferred Method
About Smart Referrals

Secure Web Transfer

Send to: Gold Coast Health Service District

Internal Referrals

Gynaecology qhRefer

Fax

(07) 5687 4497

Post

Booking and Referral Centre
Gold Coast University Hospital
1 Hospital Boulevard
Southport QLD 4215

Enquiries

1300 559 083

Related HealthPathways

No directly related pathways found

HealthPathways home page

Service Availability

Dr Graeme Walker

Medical Director Gynaecology

Facilities

Gold Coast University Hospital

Robina Hospital

If you would like to send a named referral, please address it to the specialist listed above, who will allocate a suitably qualified specialist to see the patient. Alternatively, you can view a full list of our specialists.

Mirena®/progesterone releasing IUD Insertion or removal, for HMB or HRTAdult