Referral Form

WARRINGTON INTEGRATED PALLIATIVE CARE HUB REFFERAL FORM

Completed form to be sent to: warccg.srhspa@nhs.net

1. PATIENT DETAILS

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Is patient aware of referral?*:

Is carer aware of referral?*:

 

2. DIAGNOSIS (eg primary and secondary cancer, non-malignant disease)

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Is patient aware of diagnosis?*:

 

3. COMMUNICATION REQUIREMENTS

Is interpreter required?*:

4. NEXT OF KIN DETAILS/MAIN CARER DETAILS

NEXT OF KIN
MAIN CARER

5. PLEASE CLEARLY STATE YOUR EXPECTATIONS FROM MAKING THIS REFERRAL:

Need / Response:



6. CONSENT

Has the patient consented to information being shared?*:

Does the patient have capacity consent?*:

7. CURRENT NEEDS - SERVICES AVAILABLE

Urgent / Crisis Response

  • Hospice in Patient bed
  • Rapid hospital discharge (home to die)
  • Symptom control (please state)
  • End of life care (sudden deterioration)
  • Carer breakdown (urgent package of care required)
 

Moderate / Stable but deteriorating

  • Hospice in Patient bed (non-urgent)
  • Pain and Symptom management
  • Advance care planning
  • Psychological support
  • Mobility / moving and handling
  • Breathlessness management
  • Anxiety management
  • Fatigue management
  • Dysphasia
  • Body image
 

Advice / Support

  • Bereavement support
  • Financial advice
  • Exercise / rehabilitation
  • Nutrition
  • Equipment
  • Isolation
  • Relationship support
  • Conversation for forward planning

8. GENERAL PRACTITIONERS

Is GP aware of referral?:

Is the patient on GSF register / supportive care register?:

Does the patient have an EPaCCS record?:

9. REFERRER DETAILS

10. REFERRING HOSPITAL DETAILS

11. CURRENT MEDICATION & ALLERTGIES / Relevant Treatments

12. PAST MEDICAL HISTORY

Has the patient been fitted with: A cardiac pacemaker / implanted defibrillator:

Radioactive or other implant?:

13. CURRENT SERVICES INVOLVED

14. SOCIAL SITUATIONS

Lives Alone?:

Existing Care Package:

15. INSIGHT / SPIRITUAL

(e.g knowledge of illness / prognosis, feelings & fears, importance of religion, communication issues)

16. DOCUMENTATION IN PLACE (please tick)












 

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If applicable email completed form to:

warccg.srhspa@nhs.net

 

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We might also occasionally send this information in the post. You can update your contact preferences at any time by emailing consent@stroccos.org.uk or phoning 01925 575780. We promise to respect your privacy and that the data we gather and hold is managed in accordance with the Data Protection Act 2018. For more information please see our Privacy Notice.

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