Hospice and Community Palliative Care E-Referral Form

NHS LOTHIAN HOSPICE & COMMUNITY PALLIATIVE CARE REFERRAL FORM

(Click on boxes to complete)

SPECIALIST SERVICES

St Columba’s Hospice (North Edinburgh):Inpatient unit ☐Community Services☐

Marie Curie Hospice (South Edinburgh, Midlothian):Inpatient unit☐Community Services☐

East Lothian Community Palliative Care Service:☐

West Lothian Community Palliative Care Service: ☐

For more information about the services on offer please consult

PATIENT DETAILS:

Name:Click here to enter text. Male☐ Female☐

Address:Click here to enter text.

Telephone:Click here to enter text. CHI:Click here to enter text.Age: Click here to enter text.

Current Location: Home ☐Care Home ☐Click here to enter text.Hospital Name: Click here to enter text.

Ward: Click here to enter text.

Consultant: Click here to enter text.Planned discharge date: Click here to enter a date.

NOK: Click here to enter text.

Relationship: Click here to enter text.Telephone Number:Click here to enter text.

Address:Click here to enter text.

Please can you confirm you have informed the patient and their family about this referral: Yes ☐

GP Name:Click here to enter text.GP Practice: Click here to enter text.

GP Telephone:Click here to enter text.

Diagnosis:Click here to enter text.

Other Diagnoses: Click here to enter text.

Include dates where known

Main problems/reasons for referral:

Situation: Click here. Briefly describe the current situation, with a clear concise overview of pertinent issues, including any family issues

Background:Click here. Briefly state the patient history – what got us to this point?

Assessment:Click here. Summarise the facts and give your best assessment as to what is going on

Recommendation:Click here. What action are you asking for? What do you hope to happen next?

Additional Information:Click here to enter text.

Anticipatory Care Planning:

Please detail any discussion about anticipatory care planning? Click here to enter text.

DNA CPR form:Yes☐Completion Date:Click here to enter a date.

If discussion not appropriate, please state reason here: Click here to enter text.

Referred by:Click here to enter text. Grade/Job Title:Click here to enter text.Bleep/Ext: Click here to enter text.

Date Referral Complete Click here to enter a date.

All referrals will be acknowledged within one working day.

Information about current medication:Click here. What are key current medications, or anything that hasbeen tried unsuccessfully?

Any adverse drug reactions or allergies?Click here to enter text.

If you believe your referral is urgent, please phone the relevant service to discuss as well as submitting a referral.

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