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{"sheet":"Sarcoma MDT Referral Form","index":0,"n_rows":64,"n_cols":12,"rows_kept":64,"cut":false,"hidden":false,"merged":[[10,2,10,4],[0,0,0,9],[3,2,3,4],[8,0,8,9],[1,0,1,9],[6,2,6,4],[4,0,4,1],[2,0,2,9],[6,7,6,9],[3,6,5,9],[13,0,13,1],[13,6,13,7],[3,0,3,1],[3,5,6,5],[9,7,9,9],[10,0,10,1],[9,0,9,1],[4,2,4,4],[5,0,5,1],[5,2,5,4],[6,0,6,1],[9,5,9,6],[9,2,9,4],[17,0,17,1],[13,8,13,9],[21,6,21,9],[21,4,21,5],[21,2,21,3],[21,0,21,1],[16,0,16,1],[19,0,19,9],[14,2,14,9],[20,0,20,9],[16,6,17,8],[16,9,17,9],[13,2,13,5],[14,0,14,1],[24,6,24,9],[24,0,24,1],[23,0,23,1],[23,2,23,3],[32,0,32,9],[29,6,29,9],[30,6,30,9],[29,2,29,3],[30,4,30,5],[28,2,28,3],[24,2,24,3],[23,4,23,5],[24,4,24,5],[23,6,23,9],[38,0,38,3],[34,0,34,2],[34,3,34,9],[35,0,35,2],[36,0,36,2],[35,3,35,9],[36,3,36,9],[38,4,39,9],[44,0,44,2],[44,3,44,9],[43,0,43,2],[15,2,15,9],[15,0,15,1],[17,2,17,5],[41,0,41,9],[27,0,27,9],[28,6,28,9],[29,0,29,1],[30,0,30,1],[22,0,22,1],[22,2,22,3],[22,4,22,5],[22,6,22,9],[30,2,30,3],[12,0,12,1],[11,8,11,9],[12,6,12,7],[12,2,12,5],[42,0,42,3],[11,0,11,1],[11,2,11,5],[11,6,11,7],[29,4,29,5],[28,4,28,5],[25,6,25,9],[25,0,25,1],[25,2,25,3],[25,4,25,5],[28,0,28,1],[33,0,33,9]]}
["\n\nSOUTH WALES  \nSOFT TISSUE SARCOMA MDT REFERRAL FORM\n"]
["Please ensure all sections of the form are completed, incomplete forms will be returned to the referrer.\nThe deadline for patients to be added to the MDT list for discussion is 12:00pm Friday.  The MDT is held weekly on a Wednesday\n\nReferrals can be sent using the 'click here' button at the bottom of this form and then 'Yes' when prompted.  Alternatively, attach this form to send by email to Sarcoma@wales.nhs.uk.  GP referrals should be made in the usual way (WCCG), this form should be completed and included as an attachment to that referral."]
["PATIENT DEMOGRAPHICS:"]
["Name",null,null,null,null,"Address & Postcode"]
["DOB"]
["NHS",null,"     "]
["Hospital Number",null,null,null,null,null,"Tel no: ","     ",null,null,null,"Pick option below"]
[null,null,null,null,null,null,null,null,null,null,null,"Bronglais"]
["REFERRAL DETAILS:",null,null,null,null,null,null,null,null,null,null,"Glangwili"]
["Date of Referral:",null,null,null,null,"Priority of referral:",null,null,null,null,null,"Llandough"]
["Reason for MDT Review: Tick all that apply\n",null,"Note: Retroperitoneal, Intra-abdominal and bone tumours will not be accepted.  Please make an appropriate external referral, see Guidance Notes Tab for information.",null,null,null,null,null,null,null,null,"Morriston"]
["Referring GP:\nGP referrals should be made in the usual way (WCCG) and this form included as an attachment.",null,null,null,null,null,"Referring GP Practice:",null,null,null,null,"Neath Port Talbot"]
["Referring Consultant:",null,null,null,null,null,"Referring GP Hospital:",null,null,null,null,"Nevill Hall"]
["Diagnosis / Provisional Diagnosis:",null,null,null,null,null,"Diagnosis Date:",null,null,null,null,"Prince Charles"]
["Clinical history:\nTo include relevant medical   history, symptoms and duration of presenting complaint\n*This is mandatory, if no significant medical history state none",null,null,null,null,null,null,null,null,null,null,"Prince Philip"]
["Drug history:\nTo include relevant drug history, providing detail of any anticoagulants",null,null,null,null,null,null,null,null,null,null,"Princess of Wales"]
["Performance Status:",null,null,null,null,null,"Is the patient aware of this referral?\nNote: the patient will be contacted  following receipt of referral and prior to MDT discussion unless otherwise requested here.",null,null,null,null,"Royal Glamorgan"]
["Patient preferences, patient understanding and relevant social issues that may influence treatment options.",null,null,null,null,null,null,null,null,null,null,"Royal Gwent"]
[null,null,null,null,null,null,null,null,null,null,null,"Singleton"]
["INVESTIGATIONS PERFORMED:",null,null,null,null,null,null,null,null,null,null,"The Grange"]
["Radiological - Please note lipomatous lesions with no suspicious features (solid components) should be fully characterised by USS and MRI prior to referral.  Referrals will be returned if these have not performed.",null,null,null,null,null,null,null,null,null,null,"UHW"]
["Investigation",null,"Date",null,"Local Case Record Number",null,"Hospital where performed",null,null,null,null,"Velindre"]
[null,null,null,null,null,null,null,null,null,null,null,"Withybush"]
["     ",null,"     "]
["     ",null,"     "]
["     ",null,"     "]
[]
["Histology",null,null,null,null,null,null,null,null,null,null,"Pick option below"]
["Investigation",null,"Date",null,"Specimen ID",null,"Hospital where performed",null,null,null,null,"0 - Asymptomatic"]
["     ",null,"     ","     ",null,null,null,null,null,null,null,"1 - Symptomatic but completely ambulatory"]
["     ","     ","     ","     ",null,null,null,null,null,null,null,"2 - Symptomatic, <50% in bed during the day"]
[null,null,null,null,null,null,null,null,null,null,null,"3 - Symptomatic, >50% in bed but not bedbound"]
["SUMMARY AND CLINICAL QUESTION TO BE ADDRESSED: \nUpdate in box below.  To start a new line, use Alt+Return.",null,null,null,null,null,null,null,null,null,null,"4 - Bedbound"]
[]
["Name of person completing form"]
["Telephone Number"]
["Email address for outcomes to be sent ",null,null,null,null,null,null,null,null,null,null,"Pick option below"]
[null,null,null,null,null,null,null,null,null,null,null,"Diagnostic MDT (DMDT)"]
[null,null,null,null,"PLEASE NOTE:  All referrals must be completed electronically and sent using the button to the left by midday on Friday for discussion at the next MDT. ",null,null,null,null,null,null,"Main MDT: ROH - New confirmed STS cases"]
[null,null,null,null,null,null,null,null,null,null,null,"Main MDT: ROH - Surgical/primary treatment"]
[null,null,null,null,null,null,null,null,null,null,null,"Main MDT: ROH - DMDT discrepancies"]
["OFFICE USE ONLY",null,null,null,null,null,null,null,null,null,null,"Main MDT: Paeds/TYA"]
["Has adequate information been provided by the referring clinician?",null,null,null,"Yes","No",null,null,null,null,null,"Main MDT: Thoracic"]
["List for MDT under:",null,null,null,null,null,null,null,null,null,null,"Main MDT: Relapse/progression"]
["Comments:",null,null,null,null,null,null,null,null,null,null,"Main MDT: Interval imaging (Onc + likely benign)"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,"Main MDT: Post resection"]
[]
[]
["Version 2.1 August 2021"]

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["Guidance Notes"]
["Referrals"]
["All secondary and tertiary care referrals should be made electronically, using the online referral form that is available on the sarcoma page of the Wales Cancer Network site. Referrals should be sent to the secure generic email account sarcoma@wales.nhs.uk.  This automated response confirms receipt of your referral.  "]
["GPs should continue to refer via the Welsh Clinical Communication Gateway (WCCG).  Referrals should be sent on an Urgent Suspected Cancer (USC) basis, to Plastic Surgery, for the attention of the Sarcoma Service.  To ensure high quality case review at the MDTM a minimum dataset is required, therefore, we recommend the online referral form available on the Sarcoma page of the Wales Cancer Network site is completed and attached at time of referral."]
["Incomplete referral forms or failure to provide adequate information will result in the referral being returned and may cause delay in management."]
[]
["Bone, retroperitoneal and intra-abdominal sarcoma"]
["Bone (and cartilage), retroperitoneal and intra-abdominal sarcoma is not managed in Wales, therefore the South Wales Sarcoma Service will not accept these referrals or act as intermediary.  Patients should be referred directly to the relevant sarcoma service in Birmingham at the point of suspicion.  Please refer to the services as outlined below for ease of reference:"]
["Suspected bone tumour referrals should be made to the Sarcoma MDT at the Royal Orthopaedic Hospital.  Referral guidance is available on their website ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"https://www.roh.nhs.uk/patients "]
["Suspected retroperitoneal or intra-abdominal sarcoma (including atypical lipomatous tumours) referrals should be made to Midlands abdominal and retroperitoneal sarcoma Unit in the Queen Elizabeth Hospital. Information can be found on their website",null,null,null,null,null,null,null,null,null,null,null,null,null,null," https://www.uhb.nhs.uk/Sarcoma/"]
[]
["Management Guidelines"]
["British Sarcoma Group - Guidance for ultrasound screening of soft tissue masses in the trunk and extremity Jan-2019"]
[]
["Clinical Sarcoma Research - UK guidelines for the management of soft tissue sarcoma"]
[]
["Clinical Sarcoma Research - UK Guidelines for the management of bone sarcomas"]