CQHHS SUB ACUTE CARE AND CHRONIC REHABILITATION (SACCR) REFERRAL FORM
Central Queensland Hospital & Health Service (CQHHS)  
Secure electronic transfer for CQ Referral Centre
Medical Objects: (XR4700000LZ)
HealthLink EDI: (qldrocop)
Or, fax to the CQ Referral Centre: (1300 017 155)

Please note that this service is currently provided in Rockhampton only and is based on the CQ University campus - for CQ referral criteria, visit CQ HealthPathways
Referral information                                                                                                                 	
* Re:<PtFirstName> <PtSurname>	* DOB: <PtDoB>  	
Referring GP:	<DrName>	
GP phone number:	<UsrPhone>	
Reason for service request:                          	<Reason for service request>	
Service requested:	<Service requested>	
Referral date:                                   	<Referral date>	
Service provider - Care Pathway:	<Chronic Disease Care Pathway>	
Priority:                                             	<Priority>	
	
Referral letter	
<Referral Letter - please detail reason for referral>	
	
Consents	
Date patient consent to referral:                  	<Does patient consent to referral?>	
Patient is willing to have surgery if required:	<Patient is willing to have surgery (if required)>	
Are you the patient's usual GP?	<Are you the patient's usual GP?>	
If no, patient's usual GP:	<If not, please provide patients usual GP or Practice>	
	
Condition / Specialty specific clinical information - CQ HealthPathways  	
Medication list	
<SelectedRx>	
	
Investigations relevant to this referral - results <3months old at time of referral	
<Ix>	
	
Imaging and reports	
How have related medical images been transferred to the hospital system?	<How have images been transferred for triage?>	
	
Standard clinical information                                                                                              	
Allergies / adverse reactions	
<Reactions>	
	
Immunisations	
<Imm>	
	
Observations	
<Observations>	
	
Family history	
<FamilyHx>	
	
Social history	
<SocialHx>	
	
Patient information                                                                                                                  	
IHI: 					<PtIHI>	
Name:	<PtFullName>	
Date of birth:          	<PtDoB>	
Gender:                               	<PtSex>	
Indigenous status: 	<PtATSI>	
Occupation:	<PtOccupation>	
	
Patient's contact details	
Residential:	<PtAddress>	
Postal (if different from above):	<PtPOAddress>	
Home:	<PtPhoneH>	
Mobile:	<PtPhoneMob>	
Does patient consent to SMS contact?	<Does patient consent to SMS contact?>	
Interpreter required:	<Interpreter required>	
Preferred language:	<Preferred language>	
	
Alternative Contact / Carer Details	
Name:	<NOKName>	
Relationship:	<NOKRelation>	
Phone:		<NOKContact>	
Are there custody or guardianship issues? 	<Are there custody/guardianship issues?>	
Details of custody/guardianship issues:	<If yes, details of custody/guardianship issues>	
Is the child in and out of home (foster) care?  	<Is the child in and out of home (foster) care?>	
Name of child safety service centre:            	<If yes, name of child safety service centre>	
Does the patient have an advance care plan?                  	<Does the patient have an Advanced Care Plan?>	
Does the patient have enduring power of attorney?    	<Does the patient have enduring power of attorney?>	
Insurance information                                                                                                               	
Medicare number:                                  	<PtMCNo>	
Medicare expiry:                                    	<PtMCExpiry>	
Pension number:                                   	<PtPensionNo>	
DVA number:                                         	<PtDVANo>	
Health fund:                                           	<PtInsFund>	
	
Referring GP's information                                                                                	
Name: 		 	<DrName>	
Provider number: 		<DrProviderNo>	
Practice details: 			<Practice>	
Address:	<UsrAddress>	
Phone:	<UsrPhone>	
Fax:				<UsrFax>	
Email:				<PracEmail>	
	
I look forward to hearing the outcome of this patient's consultation.	
	
Yours sincerely,		
<DrName>