Referral Form Page 1 of 2

Skin Care Service Referral Form

Skin Care Service Cottage 2, Newhall Campus

Longmoor Lane Liverpool L10 1LD

Tel: 0151 296 7529 Fax: 0151 296 7528

Please Complete all Sections A-E Referral Date ___/___ /___

For ALL referrals: Copy of the first 3 pages from the Single Assessment Process included? Yes / No For LEG ULCER patients: Copy of Lower Leg assessment included? Yes / No For TNP/VAC THERAPY patients: Copy of the VAC Therapy Additional Information? Yes / No

A (Please Tick One Box Only)Has the Patient been seen by Skin Care Service before? Yes / No If Yes, please state when and where:

Tissue Viability Pressure Ulcer � Non healing wound �Facilitae TNP discharge from hospital � Other (provide details below) �Leg Ulcer (refer to leg ulcer pathway) Venous ulcer not healed within 12 weeks � Mixed aetiology not healed within 24 weeks �ABPI outside the RCN guidelines � Non healing skin condition to lower leg �Well Leg referral (ambulant patients ) � Other (provide details below) �Dermatology (Housebound only) Non resolving skin condition �Details / History of problem and treatment tried:

B (Please Tick One Box Only) (Please Tick One Box only)

Non urgent - Will be prioritised and placed on waiting list Is Patient able to attend Clinic? (not applicable for Dermatology)

Urgent- to be seen in 48 working hours where possible Please give rationale:

Home Visit

C DReferrer Contact Details Patient GP Details

Print Name Surgery Address

Signature

Designation

Neighbourhood & TeamMobile Phone No

Tel No Base

Fax No Base Tel No Fax No

E Patient DetailsSurname Forename

Patient Address DoB

NHS

Male / Female

Tel Home Tel Mobile

Ethnicity Please refer to the 16+1 ethnic group codes for details:

Spoken language:

Referral Form Page 2 of 2

Skin Care Service Cottage 2, Newhall Campus

Longmoor Lane Liverpool L10 1LD

Tel: 0151 296 7529 Fax: 0151 296 7528

(Please DO NOT fax this sheet back)

The Skin Care Service (SCS) is a team of expert nurses that have undergone additional training and development in aspects of skin care. Our aim is to improve patient outcomes in Liverpool Community Health by promoting standardised integrated best practice in Wound Care, Leg Ulcer Management and Dermatology. The Skin Service covers all Adult patients registerd with a Liverpool GP or living within the Liverpool Area.

We offer clinical leadership and support in the management of patients with complex skin condition, Leg Ulcers and Tissue Viability. Through audit, education and research, we aim to continually update knowledge base and practice built on evidence available.

Working Hours The SCS work Monday to Friday 8.30am - 5pm with exception of bank holidays and weekends.

How to Refer Please phone for a referral form to be faxed to you. All sections of the referral proforma must be completed and faxed back to the above number.

Triage of Referral All referrals will be Triaged by the Specialist Nurses within 24 working hours of receipt with exception of bank holidays and weekends; the referrer will be contacted where applicable for telephone advice and to arrange joint visits. A rationale must be given for urgent referrals needing patient contact. Visits that are deemed urgent will be arranged where possible within 48 working hours of receipt of referral.

Level of Intervention 1. Advice given over the phone about generic skin conditions/aetiology and wound

management products will not be patient specific information but follow evidence basedprinciples of practice. The referrer is clinically responsible for the treatment prescribedfollowing the advice.

2. Single joint visit with referrer, advice and education will be offered for the management of thepatients care. Responsibility for monitoring of efficacy, adverse reactions, interpretation ofinvestigations and the re-assessment of the patient treatment plan will remain with the referrer.

3. With highly complex patient, the SCS and the referrer will agree an action plan for the managementof the referring problem. Responsibilities for holistic care of the patient will remain with the referrer.

4. Patients in Nursing or Residential Homes must be assessed and referred by District Nurses prior toreferral to the Skin Care Service.

Exclusion CriteriaPatients with following conditions can not be accepted by the Skin Service:

1. Lymphoedema (without a wound or skin condition to lower leg)2. Chronic Oedema3. Cellulitis4. Critical Ischemia (refer urgently to secondary care)5. Suspected Maliganacy (refer urgently to Dermatology secondary care).

Skin Care Service Referral Criteria