Venous disease
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If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.
- Crescendo or multiple recent TIA (Transient Ischemic Attack) / amaurosis fugax
- Acute stroke
- Acute aortic dissection
- Ruptured AAA
- Symptomatic AAA (abdominal/back pain/tenderness, compressive symptoms, distal embolisation)
- Axillary vein thrombosis, iliofemoral DVT
- Acute DVT
- Active infection in leg with peripheral arterial disease
- Diabetic foot infection (refer to high-risk foot pathway)
- Acute arterial ischemia/threatened limb
- Ischaemic changes and/or threatened limb (ulcer, gangrene, rest pain)
- Active infection in leg with peripheral arterial disease
- Diabetic foot infection (refer to high-risk foot Healthpathway)
- Foot ulcer with infection and systemically unwell or febrile, invasive infection or rapidly spreading cellulitis (defined by peripheral redness around the wound >2cm), acute ischaemia, wet gangrene, acute or suspected Charcot - A
- Thrombosed AVF (refer to vascular registrar on call or the renal access nurse)
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| Category 1 (appointment within 30 calendar days) |
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| Category 2 (appointment within 90 calendar days) |
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| Category 3 (appointment within 365 calendar days) |
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Please insert the below information and minimum referral criteria into referral
1. Reason for request Indicate on the referral
- To establish a diagnosis
- For treatment or intervention
- For advice and management
- For specialist to take over management
- Reassurance for GP/second opinion
- For a specified test/investigation the GP can't order, or the patient can't afford or access
- Reassurance for the patient/family
- For other reason (e.g. rapidly accelerating disease progression)
- Clinical judgement indicates a referral for specialist review is necessary
2. Essential referral information Referral will be returned without this
- History and examination findings in particular commenting on:
- bleeding venous ulcer
- venous ulcer
- thrombophlebitis
- DVT
- lipodermatosclerosis
- varicose eczema
- previous surgery
- details how varicose veins limit activity (executing activities) and participation restrictions (involvement in life situations) e.g. standing long periods at work.
- Conservative measures trialled
- If peripheral arterial disease, please indicate if ulcers or ischaemic rest pain.
- If history of DVT: ensure hypercoagulable screen and coag results
3. Additional referral information Useful for processing the referral
- U&E, FBC results
- USS mapping of varicose veins
4. Request
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Patient's Demographic Details
- Full name (including aliases)
- Date of birth
- Residential and postal address
- Telephone contact number/s – home, mobile and alternative
- Medicare number (where eligible)
- Name of the parent or caregiver (if appropriate)
- Preferred language and interpreter requirements
- Identifies as Aboriginal and/or Torres Strait Islander
Referring Practitioner Details
- Full name
- Full address
- Contact details – telephone, fax, email
- Provider number
- Date of referral
- Signature
Relevant clinical information about the condition
- Presenting symptoms (evolution and duration)
- Physical findings
- Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
- Body mass index (BMI)
- Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
- Current medications and dosages
- Drug allergies
- Alcohol, tobacco and other drugs use
Reason for request
- To establish a diagnosis
- For treatment or intervention
- For advice and management
- For specialist to take over management
- Reassurance for GP/second opinion
- For a specified test/investigation the GP can't order, or the patient can't afford or access
- Reassurance for the patient/family
- For other reason (e.g. rapidly accelerating disease progression)
- Clinical judgement indicates a referral for specialist review is necessary
Clinical modifiers
- Impact on employment
- Impact on education
- Impact on home
- Impact on activities of daily living
- Impact on ability to care for others
- Impact on personal frailty or safety
- Identifies as Aboriginal and/or Torres Strait Islander
Other relevant information
- Willingness to have surgery (where surgery is a likely intervention)
- Choice to be treated as a public or private patient
- Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
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If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.
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Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
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A change in patient circumstance (such as condition deteriorating, or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.
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Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.
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Last updated: 20 December 2021
© State of Queensland (Queensland Health) 2023
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