Appendix 10.4
Example of a direct referral form
*Please print clearly in capitals – form for faxing
PATIENT DETAILS
Surname: |
First name: |
Title: |
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Address: |
D.O.B. |
Sex: ■ M ■ F |
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NHS no: |
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Day time tel. no: |
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Best time to call patient: |
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Postcode: |
Other information (e.g. communication |
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needs, carer details): |
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GP DETAILS |
PCCC use only |
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GP Name: |
PCT: |
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Address: |
Tel. No: |
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Fax. No: |
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TO BE COMPLETED BY THE OPTOMETRIST/OMP
Please complete all information clearly to receive payment
■This patient has a cataract
■The cataract is causing the patient visual symptoms such that the quality of life is impaired e.g. for driving, reading, sewing, etc.
■I have explained the cataract surgery process, the risks/benefits and given the booklets
■The patient wishes to undergo cataract surgery under local anaesthetic
■The patient will need a general anaesthetic and/or is unsuitable for day surgery** **see back of form for criteria
Please indicate the patient’s need for surgery in which eye:
■ left eye ■ right eye ■ both eyes, priority being: ■ left ■ right
Appendix 10.4
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Refraction details from current sight test |
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V |
Sph |
Cyl |
Axis |
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Prism |
Base |
VA |
Add |
Near VA |
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LE |
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Other ocular pathology, i.e. amblyopia and relevant information: |
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Examination findings:
Anterior segment:
IOP (and instrument used):
Dilated fundus examination:
Comments (please include current medication – including eye drops, etc. – allergies or relevant medical or social issues):
OPTOMETRIST/OMP DETAILS
Name: |
Optometrist/OMP-GOC/GMC No: |
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Address: |
Accredited: ■ Brighton ■ Worthing |
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■ East Grinstead |
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■ Other – please state below. |
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I declare that the information I have given on this form is correct and complete and I understand that if it is not, action may be taken against me. For the purpose of verification of this claim, I consent to the disclosure of relevant information. I claim payment of fees due to me for work carried out under this NHS scheme.
Signature:
Date:
Print:
Appendix 10.5
Example of a patient letter at the time of referral to the hospital
To be printed on optician’s own headed paper or at least to be typed with their contact details in this top corner.
date
Dear Patient’s name,
I have today referred you for cataract surgery.You may now choose where you have your cataract surgery, and very shortly you will be contacted by our patient advisers who will discuss your choices with you. I have given you a booklet about your options.
If at any time in the next few weeks you have doubts about going ahead with the surgery, please contact me so we can discuss your concerns. If you have second thoughts I can arrange for you to be taken off the list for surgery and we will continue to monitor your cataract development here.
Please remember to take a list of your current medication with you to your first appointment. (Your GP surgery can print this off for you if you do not have an up to date list.) Your operation will take place very soon after the initial appointment for measurements and you will be directed back to me for a health check up and new glasses prescription.
I am enclosing a leaflet from the RNIB about cataracts that contains some helpful information.
Yours sincerely,
Name of optometrist
Appendix 10.6
An example a community post-cataract operation report form
PATIENT DETAILS (please print)
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Surname: |
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First name: |
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Address: |
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D.O.B. |
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Male |
Female |
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Tel. nos: |
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NHS number: |
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Postcode: |
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Date of visit: |
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The above named patient underwent RIGHT/LEFT cataract surgery on |
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Routine: Yes |
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If No, explain |
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Lens implant used and power: |
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Refraction aimed for: |
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The surgery was carried out at: |
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Queen Victoria Hospital, East Grinstead |
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Sussex Eye Hospital, Brighton |
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Appendix 10.6
Please complete the following and return to the appropriate hospital.
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RIGHT |
LEFT |
229 |
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Unaided visions |
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6/ |
6/ |
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REFRACTION |
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(plus cyl form) SPH |
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Cyl and axis |
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Best corrected VA |
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6/ |
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Near ADD |
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Near VA |
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SLIT-LAMP EXAM |
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Eyelids |
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Conjunctiva |
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Cornea |
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Anterior chamber |
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Pupil |
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IOL |
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Tonometry reading |
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Instrument used |
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Dilated fundus |
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Examination |
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Drops used |
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Lens used |
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Anterior segment findings |
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Additional comments: |
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Lens
Appendix 10.6
Dilated fundus examination
230
Disc
Quality standards
Has or does the patient give a history of pain, discomfort or sudden reduction in vision? Wound red or unusual in any way?
Intolerable or unacceptable astigmatism?
Intolerable or unacceptable anisometropia?
Corrected acuity <post-op PH or <6/12?
IOP (mmHg) Goldmann/NCT/Perkins R __________ mmHg L __________ mmHg
Slit lamp
Anterior chamber activity present? (>2 cells seen in 2 μ 2 mm field)
Cornea not clear?
Posterior synechiae?
Thickening of posterior capsule?
Any vitreous activity?
Are any sutures protruding or loose?
Examination not carried out (reason):