Specialist Palliative Care Referral Form - St Christopher's Hospice

Bexley Community TeamTel: 020 8320 5837Fax: 020 08320 5839Harris HospisCare with StChristopher’sTel: 01689 825755Fax: 01689 892999Queen Mary’s SidcupTel: 020 8308 3265Fax: 020 8308 3261Specialist Palliative Care Referral FormSt Christopher’s HospiceHome care:Tel: 020 8776 5656Fax: 020 8776 5798Admissions:Tel. 0208 768 4582/4669Fax: 0208 659 5051Greenwich & BexleyCottage HospiceTel: 020 8312 2244Fax: 020 8312 4344King’s College HospitalTel: 020 32994060Fax: 020 3299 4713Hospice Outreach Team -GreenwichTel: 020 8320 5837Fax: 020 8320 5786Lewisham Macmillan SupportTeamTel: 020 8333 3017Fax: 020 8333 3270Princess Royal University HospitalTel: 01689 865667Fax: 01689 864070Guy’s and St Thomas’Guy’s Site:Tel: 020 7188 4754Fax: 020 7188 4748St Thomas’ Site:Tel: 020 7188 4755Fax: 020 7188 4720Queen Elizabeth HospitalWoolwichTel: 020 8836 5442Fax: 020 8835 5428Trinity HospiceTel: 020 7787 1000Fax: 020 7787 1067(PLEASE TICK)PLEASE SEND COPIES OF RECENT CLINICAL CORRESPONDENCE WITH THIS FORMEssential Patient DetailsSurname Age: MalePatient consent to palliative careinvolvement Yes NoFirst Name DoB Is GP aware of referral Yes NoAddress Marital Status Office Use:Post CodeEthnicityTelMobile TelNHS number: Hospital No: PCT number:Primary diagnosis(es)CommunicationFluent in English? Yes No (If ‘no’ proceed with remaining questions)First Language if not English:Would interpreter be helpful to patient and Palliative Care staff? Yes NoOther barriers to communication:Next of Kin/Patient Representatives Name AddressTelephoneRelationship to patientDistrict Nurse Yes No Name Based atTelephoneFaxGeneral Practitioner Name AddressTelephoneFaxMain Carer (if different from above) Name TelephoneSocial Services Yes No Name Based atTelephoneFax/emailContinuing care assessment completed:Reason for Referral Service requested The patient is currentlyPain/symptom controlEmotional/psychological supportSocial/financialAssessment for hospice admissionCarer supportOther reason e.g. (spiritual,lymphoedema)Home assessment and supportHospital assessmentDay CareAdmission (circle)respite / symptom control / terminal careAt HomeIn Hospital (see over)Other e.g. Nursing HomeDoes patient live alone? Yes NoMRSA Status Positive Negative Not knownReferrer’s Name: (please print) Contact number: Bleep no:Hospital/Surgery:This information required on both pages if faxingIS REFERRAL URGENT (assess within 2 working days)? Yes NoIF URGENT, PLEASE PHONE US FOR IMMEDIATE ADVICE

Specialist Palliative Care Referral FormPATIENT NAME ……………………………………………In-Patient detailsHospitalTelephoneWard Direct Ward Ext. Date of discharge (if known)Consultant Is Palliative Care team involved? Yes NoBrief History of diagnosis(es) and Key treatmentsDate Progression of disease and investigations/treatment Consultant and hospitalCurrent problems (including psychosocial or spiritual issues)1. 4.2. 5.3. Patient Mobility:Any other comments/informationReferrer’s expectation of current treatment Symptom controlEstimated prognosis daysInsightHas patient been told diagnosis? Yes No Is the carer aware of patient’s diagnosis? Yes NoDoes patient discuss the illness freely Yes No Has resuscitation been discussed? Yes NoPast Medical and PsychiatricHistoryCurrent MedicationKnown Drug Sensitivities/Allergies:Yes NoDetails:Please ensure patients are aware information will be held on computer according to the Data Protection Act.Referrer’s signature:Name: (please print)Job title: Contact number: Bleep no:Surgery or Hospital:Date:Revised South East London Cancer Network April 2010