POAC Radiology Request Form

POAC Radiology Request Form

Auckland, Counties Manukau and Waitemata Districts
IMPORTANT NOTE REGARDING POAC SCANS:

POAC provides coordination and funding of radiology services to avoid acute hospital admission and to support early discharge from the hospital. Non-urgent scans should be referred via Access to Diagnostics or e-Referral.

Maternity:

This is for clinically urgent scans only (required within 24-48 hours) for the indications below. POAC does not fund or co-ordinate routine pregnancy scans.
- Suspected Ectopic Pregnancy (with named specialist endorsement)
- Retained products of conception
Counties Manukau provides a separate service for coordinating access to clinically urgent obstetric scans. Specific clinical criteria apply, refer HERE

Pelvic Ultrasounds:
- Refer to the POAC pelvic ultrasound funding policy here. All other requests will be returned to the referring clinician.
- POAC facilitates access to ultrasound under the Abnormal Uterine / Post Menopausal Bleeding pathways, for Counties Manukau residents only. Auckland and Waitemata should be submitted via e-Referral or ATD. See details here.
- Please note there is currently limited access to community pelvic ultrasound, please consider alternative management prior to submitting this referral.
Date

DayMonthYear
Date
Eligibility confirmation*

I certify that this patient is eligible for public funded health services.
Mobility Issues

Patient is immobile and will require assistance with transfers (unable to self transfer from wheelchair to bed). Community radiology is not suitable, please refer to hospital radiology.Wheelchair, able to self-transferNo mobility concerns
Community radiology is not suitable, please refer to hospital radiology.
View MoH Eligibility Guide here
Patient domiciled District*

AucklandWaitemataCounties Manukau
ACC number (where applicable)
Referring organisation*
Referring clinician*
Clinician registration number*
Referred by*

General PracticeUrgent Care ClinicEmergency DepartmentHospiceHospitalOther
Radiology reporting and follow up

I confirmer, as requestor, that I will be responsible for reviewing the radiology report and follow up with the patient, OR will contact the patient's GP to handover directlyI request that the patient's enrolled GP, as named below, review the report and provide any required follow up
Copy of report to GP for review (Name and Practice)*
This is a required field, please ensure correct details provided for reporting purposes
Referrer phone contact (mobile preferred)*
Mobile phone number is preferred where possible
Referrer phone contact notes
Referrer email*
Patient NHI*
Date of birth*

DayMonthYear
Patient name*

First NameLast Name
Gender*

MaleFemale
Address*
Current address at time of referral
Patient phone number (s)*
Please provide multiple phone numbers if available to ensure ease of contact
Ethnicity*
Urgency*

Within 24 hours24-48 hoursWithin 1 week, pre-approved by POAC
Radiology Request Type

Abdomen - Upper - ultrasoundCarotid doppler ultrasoundDVT - right leg - ultrasoundDVT - left leg - ultrasoundDVT - right arm - ultrasoundDVT - left arm - ultrasoundDVT - bilateral leg - ultrasound (with haematology endorsement)Musculoskeletal ultrasound (with acute symptoms)Pelvic ultrasound acute (POAC does not scan for ovarian cyst or mass, refer via ATD/eReferral)Pelvic ultrasound AUB (Counties Manukau residents, with criteria met for AUB/PMB pathway. Negative pregnancy)Renal ultrasoundScrotum ultrasoundSoft Tissue Ultrasound - Foreign Body or AbscessCT KUBCT Head (non-ACC/injury)CT Other (as defined below)Xray - ChestXray - AbdomenXray Musculoskeletal (specify site)Other
Pelvic Ultrasound

Retained products of conception (RPOC)Suspected ectopic pregnancy - with gynae endorsementSuspected pelvic collection - not responding to PID treatment OR suspected adnexal massAcute ongoing pain following ED presentation (with negative pregnancy test)Lost IUCD strings WITH significant pain
CT Other*
Indicate scan type, include if contrast required
FASTING REQUIREMENTS: Nil food within at least four hours. Water or black sugar free tea/coffee only consumed.*

Next day scan - patient informed of fasting requirementsSame day scan - patient has been fasting minimum four hoursNot fasted or informed of requirements (scan will be scheduled once POAC has contacted patient)
CT scan requests:
- All CT requests are non-contrast unless specified
- Ensure the possibility of pregnancy is excluded
- Confirm all clinical red-flags are excluded prior to referring
Abnormal Uterine Bleeding (AUB) Pathway Criteria*

The referrer confirms patient 1. resides within the Counties Manukau district 2. meets all clinical criteria for funding and 3. patient is NOT pregnant
Signs and symptoms of DVT, plus one of the following:*

PregnancySuperficial thrombophlebitisUpper limbWells Score 2 or moreElevated D-dimer
Pregnancy test for CT imaging*

Confirmed negativeNot applicable (no chance of pregnancy, not within child bearing age)
D-dimer result*
Body site
Name of endorsing specialist
where applicable
Clinical indication and medical history*
Additional considerations or barriers identified:

Language barrier with no support personTransport (uber/taxi) requiredWheelchair bound - must be able to transfer to bed. Community scan is not suitable for immobile patients, please refer to hospital radiology
Form to be printed and signed, patient to take this form to appointment
FOR POAC USE:
Appointment date and time

DayMonthYear
DateHourMinutesAM/PM Option
Radiology provider name
POAC comments
Signature:
Print and sign
Should be Empty: