Palliative Care Referral for GPs

Patient Name: <<Patient Demographics:Full Name>>
Date of Birth: <<Patient Demographics:DOB>> Age: <<Patient Demographics:Age>> Sex: <<Patient Demographics:Gender>>
Address: <<Patient Demographics:Address Line 1>> <<Patient Demographics:Address Line 2>>, <<Patient Demographics:City>> <<Patient Demographics:Postcode>>    Phone number: <<Patient Demographics:Phone (Mobile)>>

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 palliativ>> - 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 palli>> - Referral to palliative care	
Has the patient consented for referral to the community based palliative service? <<Has pt consented for referral>> 	
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 (includ>> - 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) 	
<<Clinical Details:Medication List>>	
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 (includ>> - Medical treatment decision maker (attach or email with referral)	
Investigation Results	
<<Summary:Investigation Results (Selected)>>	
Sender 	<<Doctor:Name>> <<Doctor:Qualifications>> 
Provider No. <<Doctor:Provider Number>>	

Referral may not be accepted without the above information