Children’s Community Nursing Services Referral

PLEASE CALL 07827954082 TO ENSURE THAT TEAM HAS CAPACITY FOR THIS REFERRAL

Name: M / F
D.O.B: Please Affix a patient label
NHS No:
Hospital No: / Address:
Postcode:
Home Telephone No:
Parent/Guardian:
Mobile No(s):
Religion:
Ethnicity: / GP:
GP Address:
Postcode:
Contact No:
H/V or School nurse:
Contact No:
School/Nursery: / Safeguarding: Yes / No
Details:
Other Professionals:
Diagnosis:
Date Admitted: / Date Discharged:
Reason for Referral:
Past medical History:
Treatment given as inpatient:
Discharge observation: / HR / RR / SATS / O2 Requirement / BP / TEMP
Weight on Discharge = ______Kg Date Weight taken =
Allergies:
Feeding and Elimination: Route – Oral / NG / Gastrostomy / Parenteral
Feed Type: Daily Intake: Frequency:
Tube Size FG: Tube Type: Last Changed: Parents Trained: Yes / No
Please select where appropriate: Constipation / Diarrhoea / Vomiting
Started:
Discharge medication:
Name:
(Please Print)
Signature: / Department:
Contact No:
Date of Referral:
Name:
D.O.B: Please Affix a patient label
NHS No:
Hospital No:

Please Note 1st and 2nd dose MUST be given in hospital.

Antibiotics / Dose / Mg/ Kg
Treatment Length:
Number of days required: / Infusion Bolus
Blood cultures required Y / N / To be followed up by:
Date:
Blood Levels Taken: ______What drug: ______
Date taken: ______Result: ______
WE CAN NOT GIVE THE MEDICATION WITHOUT THESE:
TO GO HOME WITH PATIENT:
Copy of drug chart supplied ∏ / Medication and supplies ∏ / CCN Contact Number ∏
Any other equipment required:
Wound site / Date of surgery
Cause of wound: / Date last dressed:
Packing required: Y / N
Length of packing used: / Dressing(s) used:
Analgesia required Y / N
Type Provided: Paracetamol / Ibuprofen / Codeine Phosphate / Other / Supplies sent with patient Y / N
Please ensure that adequate supply is provided especially if discharged around the weekend
Dressing instruction: / Any other information:
Name:
(Please Print)
Signature: / Department:
Contact No:
Designation:

SPOC: Tel: 07827954082

Hemel : Tel: 01442 454667 Fax: 01442 454463

E-mail:

Jan 2016 LC