DISTRICT NURSE PATIENT REFERRAL/RECORDS / NHS number:
Surname / Forename(s) / Date of birth / Gender / Marital status
Address / Telephone number / Occupation
Post code / Access (special instructions, e.g. key code)
Name of contact / Relationship / Contact’s address / Contact’s telephone number
GP / Telephone No / District nurse / Telephone No / Out of Hours Telephone No
Diagnosis and other significant conditions: / Details of nursing requests: / Referred by (name):
Ward:
Telephone:
Date and time:
Falls risk: / Waterlow score:
Pressure ulcers: / Date of first contact: / Social care package (if any)
Grade: / Site: / Telephone/Visit
Other care professionals visiting home on discharge / Name (if known)
Community Matron Yes / No
Hospice at Home Yes / No
Mountbatten Nurse Yes / No
Macmillan Nurse Yes / No
Specialist Nurse Yes / No / Discharge from district nursing:
Social Care Yes / No / Date:
Voluntary Agency Yes / No
Midwife Yes / No / Discharged to:
Other Yes / No

IMPORTANT INFORMATION:

These notes form part of your health records which are legal documents. Please return to the GP practice on completion of treatment.

COMMUNITY HOME VISIT REFERRAL FORM – Risk assessment /
Patient name: / NHS number:
Are there any infection control issues (e.g. MRSA, CDiff, etc.) yes / no (delete as appropriate)
If yes, please give details:
Is the patient being discharged with a DNACPR decision/purple form? yes / no (delete as appropriate)
HOME CIRCUMSTANCES This is for the safety of the nurses who visit patients in their own homes
Delete as appropriate
1. / Does the patient live alone? / yes / no
2. / Does the patient have known history of confusion, violence or aggression? / yes / no
3. / Has any staff member felt threatened, intimidated or harassed by any member of the household (present or past)? / yes / no
4. / Are you aware of any animals in the property? / yes / no
If yes, ask when possible:
5. / Confirm you have informed the patient of the intended visit / yes / no
6. / Is the patient mobile? / yes / no
7. / Does the patient have any speech, sight or hearing problems? / yes / no
If yes, please give details:
If the visit is after dark please answer the following questions:
8. / Is the property easy to locate? / yes / no
9. / Is there parking available? / yes / no
10. / Is the parking area close and well lit? / yes / no
11. / Is the surrounding area well lit? / yes / no
12. / Are roads, footpaths/driveways and access in good condition? / yes / no

Patient discharge from hospital check list

The following products have been sent home with the patient:

Drug Administration

Product / Tick
Signed drug administration sheet / Fax a copy of the prescription or signed permission to give slip to 534104/534413

It takes 2 working days to generate and fill a prescription from the GP.

Wound Care

Product / Tick / Product / Tick
3 x dressing packs / 3 x saline
3 x primary dressings / 3 x pairs of gloves
Tape to fix dressings/bandages
If appropriate:- / If appropriate:-
3 x secondary dressings / 3 x bandages

Catheter Care

Product / Tick / Product / Tick
Spare catheter / 1 x day/leg drainage bag
3 x night drainage bags / Sterile catheterisation pack
1 x tube instillagel / 1 x pair sterile gloves
1 x non sterile gloves / 2 x 10ml syringes
10ml ampoule of water for injection / Sterile needle

Continence Care

Product / Tick
Continence pads/products to total 7 days supplies

It will take a week to assess a patient and request continence products for delivery.

Completed by: ______Date: ______