Palliative Care Referral for GPs

Patient Name: <PtFullName>
Date of Birth: <PtDoB> Age: <PtAge> Sex: <PtSex>
Address: <PtAddress> <PtStreet>, <PtCity> <PtPostcode>    Phone number: <PtPhoneMob>

Primary Contact Name: <Primary Contact Name>    Phone number: <Primary Contact Phone Number>

Treating Specialist: <Treating Specialist>
	
Referral Details	
Has there been discussion with patient regarding:
<Discussion w Pt re Diagnosis> Diagnosis      <Discussion w Pt re Prognosis> Prognosis      <Discussion w Pt re referral to palliative care> referral to palliative care	
Has there been discussion with family/carer/medical treatment decision maker regarding:
<Discussion w Others re Diagnosis> Diagnosis      <Discussion w Others re Prognosis> Prognosis      <Discussion w Others re Referral to palliative care> Referral to palliative care	
Has the patient consented for referral to the community based palliative service? <Consent (Choose one) Yes>   Yes     <Consent (Choose one) No>     No  	
Urgency of Referral	Assessment and / or admission requested within
<Urgency (Choose one) - Crisis> CRISIS: CPC Consultation within 24 hours (phone call to palliative care service required)
<Urgency (Choose one) - Urgent> URGENT: CPC consultation within 72 hours (phone call to palliative care service required)
<Urgency (Choose one) - Non-Urgent> NON-URGENT: CPC consultation within 7 days
<Urgency (Choose one) - Routine> ROUTINE: CPC consultation within 14 days	
Diagnosis	<Diagnosis>	
Reason for referral to palliative care	<Reason for Referral>	
Diagnostics	<Recent medical correspondence (include)> recent medical correspondence (attach or email with referral)
<Recent screening/imaging results (include)> recent screening/imaging results (attach or email with referral)
<Recent blood results (include)> recent blood results (attach or email with referral)	
Current medication	(Dose, route, frequency, time of last medical review, medical allergies) <SelectedRx>	
Other comments 	<Other Comments>	
Extra Correspondence (if available)	<Goals of Care (include)> Goals of Care (attach or email with referral)
<Advance Care Directive (include)> Advance Care Directive (attach or email with referral)
<Medical treatment decision maker (include)> Medical treatment decision maker (attach or email with referral)	
Investigation Results 	<Ix>	
Sender 	<DrName> <DrQualifications> 
Provider No. <DrProviderNo>	

Referral may not be accepted without the above information