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: Date Format: MM slash DD slash YYYY NHS Number:Occupation:Ethnic Origin:Marital Status:SingleMarriedSeperatedDivorcedWidowPrefer Not to SayPatients Preferred contact details:Next of kin / primary carer: First Last Relationship:Contact No:Date of referral: Date Format: MM slash DD slash YYYY Patient location at time of referral:e.g. which hospital/ward or homeReferred 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 daysROUTINE - Contact within 10 working daysIs death anticipated within:MonthsWeeksDaysHas the patient consented to this referral?YesNoHas the patient consented to share their electronic records?YesNoIs the NoK aware of the referral?YesNoGP Details:GP Name:Surgery:Is GP aware of the referral?(All RAPID referrals must also be referred to the District Nursing Team)YesNoDistrict Nurses aware of the referral?(All RAPID referrals must also be referred to the District Nursing Team)YesNoConsultant: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 supportCare whilst dyingEthical decision makingService requested:Community assessmentAssessment for IPU admissionCounsellingLNFH 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:YesNoBariatric needs:YesNoPlease specify bariatric needs:Care package CHC funded?YesNoLone 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)NoDoes the patient have a DNACPR?YesNoIs Just in Case medication prescribed?YesNoPreferred place of CAREHomeHospiceHospitalNot KnownPreferred place of DEATH:HomeHospiceHospitalNot KnownDocument Upload:Most recent clinic letters/scans Drop files here or Medication list and allergy information Drop files here or GP summary including past medical history Drop files here or Advance Care Plan / ADRT Drop files here or
