Palliative Care Northumbria Referral Form

TYPE OF REFERRAL (please tick): Routine Urgent– please ring or bleep
PATIENT Name: / NHS number:
Date of birth: Age: / Hospital number:
Address: / Occupation:
Religion:
Allergies:
Telephone: / Current location of patient:
Is patient aware of referral?
Yes No / Is consultant/GP aware of referral?
Yes No
GP Name: / Next of kin Name:
Address: / Relationship:
Address:
Telephone: / Telephone:
TICK WHICH OF THE FOLLOWING SERVICES YOU REQUIRE AND FAX FORM TO RELEVANT NUMBER. IF URGENT, PLEASE RING RELEVANT TEAM
PALLIATIVE CARE UNIT ADMISSION
Northumbria Palliative Care Unit N. Tyneside / Fax 0191 235 4909 or phone 0191 235 4903
Northumbria Palliative Care Unit Wansbeck / Fax 01670 529961 or phone 01670 529964
HOSPITAL WARD ASSESSMENT
NorthTynesideHospital / Fax 0191 220 5901 or phone 0191 220 5905
WansbeckHospital / Fax 01670 529270 or phone 01670 529541
HexhamHospital / Phone 01434 604008
COMMUNITY ASSESSMENT (If unsure which team, please either telephone or fax to the one you think. We will forward internally if required
N. Tyneside Community / Fax 0191 220 5901Phone 0191 220 5905
South East Northumberland Community / Fax 01670 394713 Phone 01670 857635
North Northumberland Community / Fax 01665 510581 Phone 01665 626713
West Northumberland Community / Fax 01434 600739 Phone 01434 604008
CONSULTANT SERVICES
N. Tyneside community visit / outpatient clinic / Fax 0191 235 4909 Phone 0191 235 4904
Northumberland community visit / Fax 0191 246 9072 Phone 0191 285 0063
Wansbeck outpatient clinic / Fax 01670 529305 Phone 01670 529441
DAY HOSPICE
Day Hospice North Tyneside / Fax 0191 220 5901 or phone 0191 220 5949
PATIENT NAME: / DATE OF BIRTH:
CONSULTANTS/ NURSE SPECIALISTSINVOLVED Name & location: / REFERRED BY:
Name:
Job Title:
Contact number:
Date of referral:
DIAGNOSIS & PAST MEDICAL HISTORY
Is patient aware of diagnosis? Yes No / Is patient aware of prognosis? Yes No
Does patient have: an advance care plan advance decision to refuse treatment DNAR
REASON FOR REFERRAL (please tick all that apply)
Pain Symptom control Psychological End of life care Social Spiritual Rehabilitation Assessment for palliative care admission Other Please specify:
WHAT ARE THE PATIENT’S MAIN CONCERNS AT THE MOMENT?
MEDICATION(please include current medication, any medication tried so far including reason for stopping it & any allergies)
SOCIAL HISTORY & ANY OTHER RELEVANT INFORMATION
OUTCOME OF REFERRAL (for office use only)
Date patient seen:
Date referral form created: July 2011 / Who was patient seen by
Date for review: