Referral data set for referrals to Southampton University Hospitals…

Referral data set for referrals to
Southampton University Hospitals Trust
The following information is required in order to process the referral as efficiently as possible, ensuring that we
have all the relevant information about the patient. Please complete and send within 48 hours of decision to
refer
Referring Organisation
 Organisation name:                                       Treatment
                                                          function code
 Organisation code                                        Contact name
 Referring Consultant                                     Contact Phone
 and code
 Specialty:                                               Contact e mail
Who is to receive the referral?
 Receiving organisation:                                  Receiving Consultant:

 Specialty and treatment code:                            Date MDS sent:

Patient details:
 Patient surname:                                         Forename

 Patient title                                            Date of birth:

 Address:                                                 Email:

 Home Phone                                               Work Phone:

 NHS number:                                              Local patient identifier

GP details
 Name of GP:                                              GP practice post code:

 PCT code:                                                GP practice code:

18-week information:
 Unique pathway identifier:                             Organisational code:

 Current RTT status: Is the patient on an 18-week RTT pathway? Y/N

 Is this referral for:
 Diagnostic test only? Y/N
 Opinion only?          Y/N
 Is this referral the:
 Start of a new pathway? (New condition or change of treatment)
 Continuation of an active pathway (1st definitive treatment not yet given)
 Continuing treatment for a stopped pathway (1st definitive treatment given)
 18 week clock start date
 Date the patient started on this pathway or
 date of this referral if it starts a new pathway.
 Date of decision to refer to SUHT:

 List all organisations involved in the 18 week pathway by organisation code

Please print and send with referral letter.