Complete a referral form according to the requirements of the New Zealand Ministry of Health.
Write a dermatological case history
Describe dermatological examination findings
A patient presents with a skin complaint. You decide to refer the patient to a dermatologist for further management. In this exercise, you will complete a standardised referral form to the local hospital's skin clinic.
The New Zealand Ministry of Health requires standard referral forms to have the following minimal information.
Patient details: full name (and any alias) and if appropriate the name of the parent or caregiver, address, telephone number (home and alternative), date of birth, ethnicity
GP details: name, address, telephone number of referred doctor
Patient hospital number (NHI)
Accident status and claim number (if ACC)
Reason for referral (in line with referral guidelines)
Presenting symptoms and duration
Past history, details of previous treatment, current, medications
Details of previous radiological and other investigations
Recent test results and relevant old ones (dated)
Associated medical conditions that may affect treatment
Relevant details of social circumstances
Associated drug allergies
GP assessment of urgency, loss of function, pain
Write a referral for a woman in her mid-20s that suffers from moderate psoriasis. She is severely depressed and takes various relevant medications.