Fillable Endoscopy Campbell River Central Intake Referral Form (Island Health)

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Endoscopy Campbell River Central Intake Referral Form (Island Health)

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Campbell River Direct to Endoscopy Program
(CRDTE) FAX Number 250-286-7115
Clinic to acknowledge receipt of referral by faxing ☐Acceptance letter or ☐Incomplete/returned letter
Campbell River Direct to Endoscopy Program (CRDTE)
Island Healthy March 2020
B. SEND RESULTS TO
Referring Physician
MSP# ☐ This is the Primary Care provider
Clinic name
Street Address STAMP HERE
Phone
Fax
Family Physician (if different from referring physician)
Copy to (Full name)
A. PATIENT INFORMATION
Last name
First name
Date of birth Day Month Year
PHN
Primary contact number
Special instructions
Email (optional)
Street address
City
Prov
Postal code
Translator required ☐Yes ☐No I
f yes, patients first language
C. Procedure(s) Requested (indicate All that apply)
☐ Gastroscopy ☐ Colonoscopy ☐ Flexible sigmoidoscopy +/- Banding
D. Preferred Endoscopist
Requested Endoscopist: ☐ Next Available ☐ Specified_________________________________________________________
E. Reason For Referral (required results listed in bold)
Urgent 8 Weeks
☐Iron deficiency anemia(CBC, Ferritin, anti-tTG, IgA)
☐Radiologic suspicion of CA (radiology report)
☐Blood mixed WITHIN stool
Semi Urgent 12 Weeks
0
0
☐Celiac confirmation (anti-tTG and IgA)
☐Diarrhea >6 weeks (anti-tTg, GPMP)
☐Constipation >6 weeks
☐outlet bleeding (blood on tissue or in toilet)
F. Prior Endoscopies
☐ Yes ☐ No If yes, was previous endoscopy done in VIHA ☐ Yes ☐ No
G. Criteria
CRDTE is a centralized referral program that streamlines requests for GI ENDOSCOPY at Campbell River General (CRG).
Referred patients must meet the following criteria.
1. Referrals must only be for non-emergent (> 3 weeks) GI endoscopy. Requests for emergent procedures (within 3 weeks) must be
arranged with on-call surgeon (e.g. high likelihood CA, severe dysphagia, active IBD, obstructive jaundice, severe Dysphagia).
• By calling the CRG switchboard at 250-286-7100
2. Candidates for colonoscopy with BC Colon Screening Program (CSP) will be RETURNED to the referring Physician.
• http: / / www.bccancer.bc.ca / screening / health-professionals / colon / eligibility
3. Referrals for office assessment / consultation alone should be directed to individual specialist’s offices.
4. NOT Eligible for CRDTE referral: Patients who are on dual antiplatelet medications, cardiac stents < 6 months, stroke/MI < 3 months,
need for bridging heparin.
BC
Campbell River Direct to Endoscopy Program
(CRDTE) FAX Number 250-286-7115
Clinic to acknowledge receipt of referral by faxing ☐Acceptance letter or ☐Incomplete/returned letter
Campbell River Direct to Endoscopy Program (CRDTE)
Island Healthy March 2020
AN ELECTRONIC GENERATED REFERRAL LETTER CAN BE ATTACHED INSTEAD OF FILLING OUT THIS
PAGE, ENSURE ALL INFORMATION IS INCLUDED
H. Medication (referral will be returned if not completed)
☐ No Medication
Anticoagulation/antiplatelet
☐Yes
☐No
Drug and indication:
Diabetic
(oral/insulin)
☐Yes
☐No
Drug and indication:
Iron
☐Yes
☐No
Drug and indication:
Blood Pressure
☐Yes
☐No
Drug and indication:
List all other medications that are not listed above, or attach list:
NOAC’s (e.g. Pradaxa, Eliquis, etc.) stop 3 days prior to procedure; Warfarin 5 days; Antiplatelets (e.g. Plavix, etc.) 7 days.
Iron stop 7 days; Diabetic Medication and insulin to be held morning of procedure.
Allergies ☐Yes ☐No If yes, include details
I. Physical exam
In office Rectal Exam Completed: ☐Normal ☐Findings comment:
Height cm:__________ Weight kg:__________ BMI:__________
J. Medical Information
Previous stroke
☐Yes
☐No
If yes, include details
Pacemaker/defibrillator
☐Yes
☐No
If yes, include details
Mechanical Heart
Valve/stent(s)
☐Yes
☐No
If yes, include details
Previous MI
☐Yes
☐No
If yes, include details
Congestive heart Failure
☐Yes
☐No
If yes, include details
Sleep apnea
☐Yes
☐No
CPAP ☐Yes ☐No
COPD
☐Yes
☐No
If yes, include Severity
☐Mild ☐Moderate ☐Severe
Home Oxygen ☐Yes ☐No
Renal impairment
(eGFR <30)
☐Yes
☐No
If yes, include recent eGFR
Diabetes Type I Type II
☐Yes
☐No
If yes, include details
Cirrhosis
☐Yes
☐No
If yes, include details
Other Chronic Medical Condition not listed above:
Surgical History (include dates):
Campbell River Direct to Endoscopy Program
(CRDTE) FAX Number 250-286-7115
Clinic to acknowledge receipt of referral by faxing ☐Acceptance letter or ☐Incomplete/returned letter
Campbell River Direct to Endoscopy Program (CRDTE)
Island Healthy March 2020
Required Medical Information
The following MUST be included with the CRDTE referral form or the referral will be returned and closed:
1. As per College of Physicians and Surgeons of BC, referrals must include the following:
a. A letter providing clinical history and reason for referral
b. List of current medications
c. List of patient’s medical conditions
2. All lab results and documents indicated in Sections E, F, H, I and J must be included with referral.
CRDTE Timelines
CRDTE acknowledges, accepts or rejects referrals in the following manner and timelines:
1. Accepted referrals will be acknowledged by Acceptance Letter within 14 business days. If you do not receive an
Acceptance Letter within 14 business days, please notify CRDTE by fax.
2. Incomplete referrals, or referrals lacking requested results / documents, will be returned and considered closed. If a referral
is
returned, you will receive notification via Rejection Letter within 14 business days. If a referral is rejected, a NEW
REFERRAL will need to be submitted to CRDTE, along with the missing documents.
3. If you have any questions regarding the completion of the referral form, contact the CRDTE Office at 250-286-7171.
Suitable for Direct to Scope:
1. Presumed able to follow pre procedure instruction and bowel prep when applicable
2. Patient cognitively intact and agreeable to procedure
3. Absence of major medical illness requiring assessment
4. Patients on dual antiplatelets, cardiac stents less than 6 months, stroke/MI less than 3 months are NOT appropriate for the CRDTE
program please send referrals to surgeon’s office.
Referring Clinician:
SIGNATURE PRINTED NAME AND DESIGNATION
THIS SECTION WILL BE COMPLETED BY CRDTE PROGRAM
Referral
☐ Accepted
☐ Rejected
Accepted/Rejected letter sent to family doctor
☐ yes
Triage completed By
☐ Surgeon
☐ Triage Nurse
☐ Clerical
Referral sent to
For assessment
☐ Surgeon office
_______________________________
☐ Triage Nurse
☐ CSP office
Comments
Date:
Date:
Date:
Date:
Date:
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Endoscopy Campbell River Central Intake Referral Form (Island Health)

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Completed 16 July 2020

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