For your referral request to be accepted and clinically prioritised we need the following information.
Service requested / Addressed to Clinician
- Indicate the specialist clinic or service requested
- Address referral to Head of Unit or Lead Clinician (see Specialist Clinic Directory)
Patient demographic information
- full name / date of birth / birth sex / gender identity
- address / telephone number(s) / email address / alternative contact details / preferred method of communication
- Medicare number (if eligible)
- if a person identifies as being of Aboriginal or Torres Strait Islander origin
- any requirements to ensure cultural safety (including family violence safety)
- language other than English (if applicable), reliance on a carer, reliance on cultural, linguistic or disability support (for example, need for an interpreter), reliance on transport or accommodation support
- name of parent or carer (if applicable)
- medical treatment decision-maker, support person or carer (if any)
- contact details for usual GP (if the GP is not the referring clinician)
Referrer demographic information
- full name / address / telephone number(s) and if appropriate fax number / preferred method of communication
- Medicare provider number
Required referral information
Required referral information:
- date of referral
- indication if the patient has agreed to the referral and the sharing of their personal and health information with the health service
- referring clinician’s assessment of clinical urgency (urgent or routine)
- required clinical information listed in any referral criteria for the presenting problem
Reason for referral
If the main purpose of the referral is:
- requesting services to establish a diagnosis, provide clinical assessment or inform a treatment plan
- requesting partnership care between the patient, GP and the health service (such as patients with chronic or progressive conditions who require ongoing specialist advice or services to improve and optimise people’s function and participation in activities of daily living)
- requesting specific tests or investigations that cannot be ordered, accessed or interpreted through the primary care system
- requesting treatments or an intervention.
Presenting problem
- Indicate the presenting problem or working diagnosis and if the patient has received earlier services for the same presenting problem.
Current patient management
Summary of current patient management including:
- current treatment / previous treatment and response to this treatment
- complete and current medication list
- allergies and previous adverse events
- relevant medical history including any functional or cognitive impairment
- relevant family history
- relevant physical, psychosocial and structural barriers the person experiences which may impact on their access to services
- existing community supports (if any)
- existing advance care directive (if any).
Impact of the problem on the patient
List any functional impairments, impact on work, study or school, impact on caring responsibilities, social impact, impact on comorbidities and any other impact on the person’s quality of life.
About the minimum referral information requirements
The Victorian Government's policy for Managing referrals to non-admitted specialist services in Victorian public health services sets the minimum referral information requirements. For further information on the policy, see here
