Procedure that requires prior approval prior to referral Application form: - Subacromial decompression of the shoulder Name of Referring Clinician GP Name and Surgery Patients NHS Number Is the patient/guardian aware of the proposed treatment and have they consented to you YES NO raising this request on their behalf Has the patient/guardian consented for their personal and clinical information to be provided YES NO to the IFR service to enable full consideration of this funding request? Is this a patient/guardian led application? YES NO Most Urgent: Decision needed within a week as the be in danger patient’s life may Immediate: Decision needed within 3 weeks as delay will not be clinically appropriate. Routine: Decision needed in 4 to 6 weeks. Please note Prior Approval is not required for: Red Flag symptoms for same day Emergency referral for consultants surgical opinion: Acutely painful red warm joint suspected infected joint – Trauma leading to loss of rotation and abnormal shape unreduced shoulder dislocation. – Urgent referral ( <2/52) to secondary care: Shoulder mass or swelling suspected malignancy – Sudden loss of ability to actively raise arm (with or without trauma) acute cuff – In other cases prior approval is required prior for surgical opinion and treatment. Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service: for consideration. The policy statements are available at: Clinical Criteria required for consideration of treatment Please Tick Has the patient had symptoms for at least 3 months from the start of treatment? YES NO Is this procedure being undertaken in isolation? YES NO Is it being undertaken with another procedure? YES NO Please specify: Is there documented evidence that the symptoms are intrusive and debilitating? YES NO Please provide specific details and attach documented evidence Has the patient been compliant with conservative management for at least 6 YES NO weeks: Please indicate which conservative measures have been tried: Education Rest NSAID’s Optimised analgesia Appropriate physiotherapy
Procedure that requires prior approval prior to referral Application form: - Subacromial decompression of the shoulder Name of Referring Clinician GP Name and Surgery Patients NHS Number Is the patient/guardian aware of the proposed treatment and have they consented to you raising this request on their behalf YES NO Has the patient/guardian consented for their personal and clinical information to be provided to the IFR service to enable full consideration of this funding request? YES NO Is this a patient/guardian led application? YES NO Most Urgent: Decision needed within a week as the patient’s life may be in danger Immediate: Decision needed within 3 weeks as delay will not be clinically appropriate. Routine: Decision needed in 4 to 6 weeks. Please note Prior Approval is not required for: Red Flag symptoms for same day Emergency referral for consultants surgical opinion: Acutely painful red warm joint – suspected infected joint Trauma leading to loss of rotation and abnormal shape – unreduced shoulder dislocation. Urgent referral ( <2/52) to secondary care: Shoulder mass or swelling – suspected malignancy Sudden loss of ability to actively raise arm (with or without trauma) – acute cuff In other cases prior approval is required prior for surgical opinion and treatment. Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service: for consideration. The policy statements are available at: Clinical Criteria required for consideration of treatment Please Tick Has the patient had symptoms for at least 3 months from the start of treatment? Is this procedure being undertaken in isolation? Is it being undertaken with another procedure? Please specify: YES NO YES NO YES NO Is there documented evidence that the symptoms are intrusive and debilitating? Please provide specific details and attach documented evidence YES NO Has the patient been compliant with conservative management for at least 6 weeks: Please indicate which conservative measures have been tried: Education Rest NSAID’s Optimised analgesia Appropriate physiotherapy YES NO
Subacromial-decompression-of-the-shoulder-August-2017-v.1-BE.docx