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Palliative care in the acute hospital settingA practical guide$

Sara Booth, Polly Edmonds, and Margaret Kendall

Print publication date: 2009

Print ISBN-13: 9780199238927

Published to Oxford Scholarship Online: November 2011

DOI: 10.1093/acprof:oso/9780199238927.001.0001

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Appendix 1 Referral Proforma

Appendix 1 Referral Proforma

Source:
Palliative care in the acute hospital setting
Publisher:
Oxford University Press

(p.163)

Please Use Block Capitals and Black Ink—Thank You

Eastern Sector Palliative Care Group: Referral for Specialist Palliative Care Services

Patient Details

Carer Details

NHS Number

Name of Carer

Title

Gender

M

F

Relationship to Patient

Forename

Carer Tel:

Surname

Is the patient living alone?

Y

N

Age

DOB

Where is the patient presently?

Address 1

Involved Professional Details

Address 2

PCT

HSTH

Address 3

GP Name

Post Code

Tel:

GP Surgery

Ethnicity

Religion

GP Tel

GP Fax

Marital Status

Smoker

Y

N

History of Illness

District Nurse

Diagnosis inc. known metastases

DN Tel

DN Fax

Community Specialist Nurse

Is patient aware of diagnosis

Y

N

SN Tel

SN Fax

Date of diagnosis

Hospital Consultant

Other medical conditions

Hospital Consultant

Current Medication (inc dose and frequency)

Hospital Specialist Nurse

Referral Information

GP aware of referral

Y

N

Date Patient last seen by referrer

Relevant Treatments

Any known allergies?

Pacemaker in situ

Y

N

(p.164)

Name:

NHS Number

Reason for referral. Please complete with all relevant details as incomplete forms will result inProcessingdelay

PLEASE INDICATE SERVICE REQUIRED WITH ✓ AND FAX TO APPROPRIATE NUMBER

Hospital Consultant Out Patient Clinic

01928 795157

ATTACH LETTER PLEASE

Warrington Community Palliative Care team

01925 604269

Assessment

Info Only

Halton and St Helens Community Palliative Care Team

01928 795157

Assessment

Info Only

Warrington Hospital Palliative Care Team

01925 662347

Assessment

Info Only

Halton Hospital Palliative Care Team

01928 753504

Assessment

Info Only

St Rocco's Hospice

01925 630690

Inpatient

Day care

Halton Haven Hospice

01928 701201

Inpatient

Day care

Referrer Details

Printed Name

Designation

Phone number

SIGNATURE

Date

OFFICE USE ONLY

Case sheet number

Community number

Hospice Number

Date Referral Received

Date of Initial Contact