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Referrer Contact Details:Name and Position of Referrer: Organisation:
Phone: Fax: Email: Date:
Patient Name Date of birth
Home Address
Gender ATSI YES
NO
Phone -home Phone – mobilePatient living alone YES
NOGPName and phone
Available – home visits
YES
NO
Contactable by phone after hours
YES
NO
Main Carer - Name
Relationship
Address (if different to patient address)
Phone
Main diagnosis Medical History
After Hours Palliative Care Phone Support Service:
Client Referral Please note: this service is only
operating in north and north west Tas
Client ID:
Family Name:
Given Names:
DOB Sex
2
Client alerts (cautions, allergies, risk management)Phase of Illness(Page 4 for definitions)
Karnofsky Scale(Page 4 for definitions)
Current Treatments: chemotherapy, radiotherapy, other, not applicable
Current symptoms: physical, psychosocial, other? Problem severity score (Page 4 for definitions)
Current medications Doses
Current anticipatory medication and syringe driver orders Doses
Are anticipatory medication and syringe driver orders available in the home
YES NO
Is injectable medication available in the home? YES NO
Are syringes/needles available in the home? YES NO
PlanningYES YES
Client ID:
Family Name:
Given Names:
DOB Sex
3
Does the client want to be care for at home?
Is the caregiver managing care at home?
NO NO
Does the client want to die at home?
YES Does the caregiver want the client to die at home?
YESNO NO
Any specific instructions should client die afterhours? For example, should GP be contacted to complete DOLE? Funeral Service contact? Body bequest arrangements?
Please advise – does the client have: YES NO Date Completed
Further Information?
Advance Care Directive? (please provide copy if available)Medical Goals of Care? (please provide copy if available)Enduring Guardian?
Any further information?
Client ID:
Family Name:
Given Names:
DOB Sex
Caresearch patient/carer or other information provided?www.caresearch.com.au/caresearch/tabid/1262/Default.aspx
Date
4
PLEASE COMPLETE THIS REFERRAL AND FAX TO THE PALLIATIVE CAREAFTERHOURS PHONE SUPPORT SERVICE: (03) 6273 1788
Advance Care Directive forms and information are available at:
For more information during business hours please contact:
Amanda SharmanManagerGP AssistPh: (03) 616 52344E: [email protected]
For more information after hours please contact:
Palliative Care After Hours Phone Support Service - GP AssistPh: (03) 6165 2348
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www.advancecareplanning.org.au/resources/advance-care-planning-for-your-state-territory/tas andwww.dhhs.tas.gov.au/__data/assets/pdf_file/0008/129455/FT021550_Advanced_Care_Directive_20171213..pdfMedical Goals of Care forms available at:https://www.dhhs.tas.gov.au/palliativecare/health_professionals/goals_of_care