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Perineal disease and faecal incontinence

Minimum referral criteria

Category 1 - Seen within 30 days

  • Persistent perineal sepsis.

Category 2 - Seen within 90 days

  • Fissure not responding to maximal medical treatment after 6 weeks.
  • Symptomatic obstetric anal sphincter injury (OASIS).
  • External rectal prolapse.

Category 3 - Seen within 365 days

  • Pilonidal disease/sinus.
  • Warts.
  • Uncomplicated haemorrhoids.
  • Anal skin tags and benign perianal polyps.
  • Uncomplicated anal fistula.
  • Faecal incontinence.

Standard information for all referrals

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for general practitioner or second opinion
  • For a specified test or investigation the general practitioner can't order, or the patient can't afford or access
  • Reassurance for the patient or family
  • For other reason (e.g., rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

Patient's demographic details

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Phone contact numbers – 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 Torres Strait Islander Ask the patient their ethnicity

Referring practitioner details

  • Full name
  • Full address
  • Contact details – phone, fax, email
  • Provider number
  • Date of referral
  • Signature
  • Patient's usual general practitioner (if different from above)

Relevant clinical information about the condition

  • Inclusion of Clinical Prioritisation Criteria (CPC) where relevant
  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Investigations carried out and results as indicated in the relevant pathway
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Options already pursued
  • 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

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 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, WorkCover, motor vehicle insurance)

Essential information

  • Management to date including timeline, medication, and lifestyle.
  • History of previous drainage operation.

Additional information

  • Previous gastroenterologist investigations and results (date, report, and histology results) e.g., last 2 to 3 clinic letters.
  • Endoanal ultrasound results for OASIS (useful).

Information for your patient

Expected time frame for appointment notifications

  • Once the request is received, categorisation by the hospital will occur.
  • General practitioners and patients are notified of the assigned category between 14 days to 1 month after completed request is received.
  • Patients are usually notified of the upcoming appointment time and date approximately 4 weeks prior unless short notice appointments become available.

Appointment information

  • Patients will be given an appointment via phone, SMS, or letter.
  • The patient must contact the hospital to reschedule if they are not able to attend.
  • If the patient fails to respond to 2 appointment offers:
    • They will be discharged back to their general practitioner.
    • They can have a new request for assessment sent to the hospital if the need still exists.
  • The patient's first appointment may not always be with a specialist. Where appropriate, the request may be sent to a public allied health or nursing service for initial assessment and management. A specialist assessment may then be arranged or ruled out.

Ask your patient to:

  • take a list of current medications, and all relevant radiology films and reports to appointments.
  • advise of any change in circumstance (e.g., getting worse or becoming pregnant), as this may affect the request for assessment.
  • update their contact details (e.g., phone number and address) with the hospital.
Last updated: 24 January 2020

Send referral

Specialist Outpatient Department

Fax: 1300 017 155

CQ Fracture/urgent referrals
Fax: (07) 4920 7242

Named referrals

If you would like to send a named referral, please address it to a specialist listed below.

Rockhampton

  • Dr Garry Dyke, Department Director
  • Dr Katarzyna Zalewska
  • Dr Chitrakanti Kapadia
  • Dr Yiu Ming Ho
  • Dr Michael Lamparelli

Gladstone

  • Dr Maseelan Naidoo
  • Dr Darren Lituri
  • Dr Robert Schreiber

Emerald

  • Dr Garry Dyke, Department Director
  • Dr Katarzyna Zalewska
  • Dr Chitrakanti Kapadia
  • Dr Yiu Ming Ho

> view all CQ Health specialists

Service advice

Rockhampton
Phone: (07) 4920 6440

Gladstone
Phone: (07) 4976 3169

Emerald
Phone: (07) 4987 9750

Biloela
Phone: (07) 4992 7000

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