2 Week Urgent Referral for Suspected Sarcoma	
v9 Blank    July 2018	
Ctrl-Click occg.info/OUH-SarcomaService to see more information for clinicians and patients

Patient’s details	Patient’s background and culture	
Surname		Ethnicity		
Forename		1st language		
DOB		Age		Interpreter required? Y    N 	
Sex		GP details	
Title		Referring GP		
Address & postcode		GP address		
NHS No		GP Tel no		
Hospital No		Practice Email		
Email		Referral date		
Phone Numbers	Preferred
Number(s)	Can leave messages?	Date received	     	
Home						
Work						
Mobile						

2ww referral communication checklist
it is essential that you answer all questions in this section	
I have explained to the patient that they may have cancer and I am referring them on the 2 Week Wait Suspected Cancer Pathway	 Yes	 No – why not?      	
Is the patient available for an appointment within the next 14 days?	 Yes	NB. Please only submit this referral when the answer is Yes	
Has the patient been given the Fast Track Pathway information leaflet?
Information leaflets can be printed from here Ctrl-Click occg.info/2WW-PIL 	 Yes	 No – why not?      	
IMPORTANT:
Please ensure this patient is available from referral for further hospital appointments and investigations.
Failure to check this may result in wasted appointments.
If the patient cannot attend immediately (e.g. booked travel) please negotiate a delay in referral.
Please indicate any exceptional circumstances here      	
I have explained to the patient that, to ensure they are seen within 
14 days, appointments may be offered at either Oxford or Banbury	 Yes	 No – why not?      	
Once cancer has been excluded the patient will be referred back to you, their GP, other than in exceptional circumstances where immediate onward referral is deemed clinically necessary by the secondary care clinician	

Advice on Diagnostic Testing
Ctrl-Click occg.info/NICE-2WW-Sarcoma	
Children & Young People	Unexplained bone swelling or pain	Consider a very urgent direct access X ray (to be performed within 48 hours)	
	Unexplained lump that is increasing in size	Consider a very urgent direct access ultrasound scan (to be performed within 48 hours)	
Adults	Unexplained bone swelling or pain	Consider a very urgent direct access X ray
Offer an FBC, Calcium Group and ESR to anyone 60 and over with persistent bone pain	
	Unexplained lump that is increasing in size	Consider an urgent direct access ultrasound scan (to be performed within 2 weeks) requested via ICE or Community Ultrasound Referral Form	

Referral Criteria
Ctrl-Click occg.info/NICE-2ww-Sarcoma

NB – NICE advise all referrals are made after Consideration by a clinician (i.e. not automatically)

Please complete all relevant boxes as the referral may be returned if incomplete	
ERS Service Selection
Please send as an attachment via the eReferral Service within 24hrs	
Specialty: 
Clinic Type: 
Service Name:	2WW
Select from below
Select from below	
If ERS is unavailable please email to PCC2wwOxford@nhs.net  and request a Read Receipt when sending	
Children & Young People		Ultrasound suggestive of Soft Tissue Sarcoma or if ultrasound findings are uncertain and clinical concern persists	Clinic type: 2WW Children & Young People
Service: Suspected Paediatric Cancer-2ww-Sarcoma-Oxford University Hospitals-RTH	
		X-ray suggestive of Primary Bone Tumour		
Adults		Ultrasound suggestive of Soft Tissue Sarcoma or if ultrasound findings are uncertain and clinical concern persists	Clinic type: 2WW Sarcoma
Service: OUH Suspected Sarcoma Cancer-2WW-Sarcoma Soft Tissue (NOC)-Oxford University Hospitals-RTH	
		X-ray suggestive of Primary Bone Tumour	Clinic type: 2WW Sarcoma
Service: OUH Suspected Sarcoma Cancer-2WW-Sarcoma Bone (NOC)-Oxford University Hospitals-RTH	
Location	     	Right Proximal		
		Right Distal		
		Left Proximal		
		Left Distal		
Clinical Examination

N.B See below for investigation recommendations	Swelling		
	Pain		
	Increasing in size		
	Size                   	     	
	Deep to fascia 		
	Fixed		
	Immobile		

Please add a referral letter / additional information for clinical use
(please highlight any significant comorbidities)
Failure to provide clinical information may result in delayed treatment	
	Please tick here if you are sending any additional documents
The referral narrative should be typed onto this form, not in a separate letter	
	Please tick here if the patient does not meet the 2 week wait criteria but you feel they still warrant urgent investigation under this pathway, and outline the details below
This referral will be triaged by the specialist prior to acceptance	
Please type your clinical referral in the next row	

Management of patients who are receiving anticoagulation

Information required to allow the most patients to move ‘straight to test’ prior to OPA
Failure to supply this information may delay their progress and result in unnecessary appointments 	
This patient IS NOT anticoagulated		
This patient IS anticoagulated with		
Reason for anticoagulation		
Had an INR of		On: 	
History of bleeding disorder	 No	 Yes - Details: 	

Investigations	
Investigations done	X-Ray		MRI		CT		USS		Biopsy		
Hospital		Details		
Radiology within last year		
Any investigation results not populated above:  	

Additional patient information	
Manually entered	
	Family history any cancer: 	
	Never smoked
Past smoker
Current smoker	     

	Alcohol consumption       units per week	

Performance Status Key
to be completed by GP to assist provider with booking an appropriate clinic appointment
Failure to provide this information may lead to a wasted appointment	
Fully active, able to carry on all pre-disease performance without restriction	0		
Restricted in physically strenuous activity but ambulatory and able to 
carry out light/sedentary work, e.g. house or office work	1		
Ambulatory and capable of self-care, but unable to carry out work activities 
Up and active > 50% of waking hours	2		
Capable of only limited self-care. Confined to bed or chair >50% of waking hours	3		
Completely disabled. Cannot carry out any self-care. Totally confined to bed or chair	4		

Consultations

Medication

Problems

Allergies