Referral form If you’d like to refer a patient to Oakhaven please either complete this Word document Oakhaven Hospice Referral Form or use the online form below: Specialist Palliative Care Referral Form For use by healthcare professionals wishing to refer a patient Step 1 of 3 33% Essential referral details This referral will NOT be processed without the valid consent of the patient or their proxy. Please ensure patients are aware information will be held on computer according to the Data Protection Act. Please attach ALL recent relevant clinic letters and investigations Inadequate supporting information may result in the referral being declined. 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No:Mob. No:Date of Birth: MM slash DD slash YYYY NHS Number: Occupation: Ethnic Origin: Marital Status: Single Married Seperated Divorced Widow Prefer Not to Say Patients Preferred contact details: Next of kin / primary carer: First Last Relationship: Contact No:Date of referral: MM slash DD slash YYYY Patient location at time of referral:e.g. which hospital/ward or home Referred by: Job Title: Phone: Email* Referral Priority: RAPID - Contact within 1-2 working days (All RAPID referrals must also be referred to the District Nursing Team) SOON - Contact within 5 working days ROUTINE - Contact within 10 working days Is death anticipated within: Months Weeks Days Has the patient consented to this referral? Yes No Has the patient consented to share their electronic records? Yes No Is the NoK aware of the referral? Yes No GP Details:GP Name: Surgery:Is GP aware of the referral?(All RAPID referrals must also be referred to the District Nursing Team) Yes No District Nurses aware of the referral?(All RAPID referrals must also be referred to the District Nursing Team) Yes No Consultant: Hospital: Tel No:Diagnosis(primary diagnosis/metastases/complications – including relevant treatment)What is it that you are hoping we can do?Please summarize current problems and specific aims of referral to Specialist Palliative Care Team: Reason for referral: Uncontrollable symptoms (please give details below) Emotional / psychological / spiritual support Care whilst dying Ethical decision making Service requested: Community assessment Assessment for IPU admission Counselling LNFH Hospital Palliative Care Team Additional Information:Detail any supportive interventionse.g. RIG/PEG feeding, NIV, oxygen (if on oxygen specify L/min):Detail any supportive interventionsMobility / disability issues:Any communication difficulties / needs?(patient or family/carer)Equipment needs:Care package in place: Yes No Bariatric needs: Yes No Please specify bariatric needs:Care package CHC funded? Yes No Lone worker risks that may affect safety of keyworkere.g. home environment, patient, family, pets, smoky environment: Advance Care Planning:Does the patient have an ADRT or Advance Care Plan? Yes (If yes please attach details below) No Does the patient have a DNACPR? Yes No Is Just in Case medication prescribed? Yes No Preferred place of CAREHomeHospiceHospitalNot KnownPreferred place of DEATH:HomeHospiceHospitalNot KnownDocument Upload:Most recent clinic letters/scans Drop files here or Select files Max. file size: 128 MB. Medication list and allergy information Drop files here or Select files Max. file size: 128 MB. GP summary including past medical history Drop files here or Select files Max. file size: 128 MB. Advance Care Plan / ADRT Drop files here or Select files Max. file size: 128 MB. Δ
