Patient demographic information

• full name
• date of birth
• name of parent or carer (if applicable)
• address
• telephone number(s)
• email address
• alternative contact details
• preferred method of communication
• Medicare number (if eligible)
• if a person identifies as being of Aboriginal or Torres Strait Islander origin
• any requirements to ensure cultural safety (including family violence safety)
• language other than English (if applicable), reliance on a carer, reliance on cultural, linguistic or disability support (for example, need for an interpreter), reliance on transport or accommodation support
• medical treatment decision-maker, support person or carer (if any)
• contact details for usual GP (if the GP is not the referring clinician)

Referrer demographic information

• full name
• address
• telephone number(s) and if appropriate fax number
• email address
• preferred method of communication
• Medicare provider number

Required referral information

Required referral information:

• date of referral
• indication if the patient has agreed to the referral and the sharing of their personal and health information with the health service
• referring clinician’s assessment of clinical urgency
• required clinical information listed in any referral criteria for the presenting problem

Reason for referral

If the main purpose of the referral is:

• requesting services to establish a diagnosis, provide clinical assessment or inform a treatment plan
• requesting partnership care between the patient, GP and the health service (such as patients with chronic or progressive conditions who require ongoing specialist advice or services to improve and optimise people’s function and participation in activities of daily living)
• requesting specific tests or investigations that cannot be ordered, accessed or interpreted through the primary care system
• requesting treatments or an intervention.

Presenting problem

Indicate the presenting problem or working diagnosis and if the patient has received earlier services for the same presenting problem.

Service requested

Indicate the non-admitted specialist clinic or service requested.

Current patient management

Summary of current patient management including:

• current treatment
• previous treatment and response to this treatment
• complete and current medication list
• allergies and previous adverse events
• relevant medical history including any functional or cognitive impairment
• relevant family history
• relevant physical, psychosocial and structural barriers the person experiences which may impact on their access to services
• existing community supports (if any)
• existing advance care directive (if any).

Impact of the problem on the patient

List any functional impairments, impact on work, study or school, impact on caring responsibilities, social impact, impact on comorbidities and any other impact on the person’s quality of life.

About the minimum referral information requirements

The Victorian Government's policy for Managing referrals to non-admitted specialist services in Victorian public health services sets the minimum referral information requirements.