Common Referral Form for Specialist Palliative Care Services in Suffolk

COMMON REFERRAL FORM FOR SPECIALIST PALLIATIVE CARE SERVICES IN SUFFOLK

SERVICE REFERRED TO: Please tick box....

EAST
□St Elizabeth Hospice
One Call 0800 567 0111
Fax 01473 712652
□IpswichHospital
Palliative Care Team:
Tel 01473 704932 /712233 b.610
Fax: 01473 704916 / WEST
For St Nicholas Hospice Care, please contact them direct
□West SuffolkHospital
Palliative Care Team:
Telephone/fax 01284 713776 / Referred by: Sender title and surname
Designation: GP/NP (& where works)
Contact No.
(& when available)
Date of referral: Referral date
SERVICE REQUIRED:
Admission
Community Specialist Nurse
Day Services
Domiciliary Visit
Hospice at Home
Hospital ward visit
Nurse Led Clinic
Outpatients / DEGREE OF URGENCY:
Emergency (same day)
Urgent (next few days)
As soon as possible (1 week)
Non-urgent (weeks)
Respite with date(s) ......
Medical OPA nurse consultant OPA
PATIENT DETAILS:
Who are you referring? the patient Yes □No □ family member(s) Yes □No □ both Yes □
Name: Known as: Male Female
DOB: Hospital No.: NHS No.:

Address (inc. post code)

Tel No(s).:
Is the patient: At home Care Home/other ...... In hospital
Which hospital/ward? ...... Proposed date of discharge: ......
Marital Status: Ethnic Origin: Religion:
First Language: Interpreter required?Yes □No □
Communication/Language issues

MRSA Status Pos Neg C Difficile status Pos Neg Other infection risk?
Diagnosis (inc date of diagnosis):
Other medical conditions:
Is patient aware of referral? Yes □No □ Is family aware of referral? Yes □No □
PROFESSIONALS INVOLVED:
GP: On GSF Register Yes □ No □
Practice:
Consultant:
Hospital: / DN :
CNS :
Social Worker:
OT/Physio:
Other:
CARERS: Next of Kin: First Contact:
Relationship:
Name «Next_of_kin
Address: Next of kin's address
Contact No: Next of kin's telephone / Significant Other:First Contact:
Relationship:
Name:
Address:
Contact No:

PATIENT’S NAME: DOB: NHS NO.

REASON FOR REFERRAL: (What unmet needs have triggered this referral now?)
Complex physical
Spiritual distress
Bereavement
Complex psychosocial / family
What is it that you are hoping we can do? / Rehabilitation (Palliative)
Complex EOL issues
Other, please specify
......
DETAILS OF MAIN PROBLEMS:
ADDITIONAL INFORMATION: (including psychosocial, recent bereavement(s)/losses)
CURRENT MEDICATION / ANY KNOWN ALLERGIES:
Current Repeat Issues
Current Acute Issues
Allergies
CURRENT / PREVIOUS TREATMENT:
What are your plans for follow up?
OTHER SPECIFIC PATIENT NEEDS:
Details of how to get there:
Details of Care Package(incl. any in place, Continuing Care):
Mobility/Disability Issues:
Equipment Needs (incl. any in place):
Oxygen Support Y/N please specify: Bariatric Needs Y/N please specify:
Lone Worker Issues Y/N please specify:
Are there any hazards in the home? Y/N please specify:

Signature of Referrer: Date:

Please attach copies of any relevant correspondence e.g. recent clinic letters, discharge summaries, etc.