Virtual Ward Referral Form(Interim)v4.4
(Please see Virtual Ward Guidance for Individual Ward contact details )
PATIENT DETAILS
NHS Number Gender M F DOB
Surname First Name Title
Address
Postcode Tel. No:
Age Ethnicity Religion
Patient Lives Alone Yes/No Language if not English: Interpreter Required? 
NEXT OF KIN / CARER DETAILS
Next of Kin / Carer Relationship to Patient
Address
Postcode Tel. No: Family / carer aware of referral? Yes/No
INVOLVED PROFESSIONAL DETAILS
GP Name GP Surgery
GP Tel.No GP Fax
Consultants + Trust:
Support Networks / Services:
ANY RISK TO STAFF? Infection Control  Moving/Handling  Environmental  Health & Safety 
Please state if a double visit is required Comment………………………………………………………………….
PATIENT NOT AT HOME? Please state current residence:
PATIENT CONSENT (mandatory):  The patient has consented to the referral and the sharing of relevant persona data and sensitive personal(clinical information) with the virtual ward staff
CLINICAL INFORMATION
BRIEF INTERVENTION ONLY: Urgent (< 4 hours)  Routine (24 hours) 
(Only complete other sections if relevant to the intervention)
Please tick specific services required
Pro-active Nursing / Re-ablement (non-urgent)*
Pro-active Care Programme
Medication Management
Disease Monitoring
Healthy Living Review
Palliative Care
Wound care
Health Education
Other / 






 / Occupational Therapy
Domiciliary Physiotherapy
Social Assessment
Housing review
Voluntary services #
Speech and Language Therapy
Other / 






REASON FOR REFERRAL: (please comment on main problems, medical condition, any evidence of cognitive deficit , and their impact on physical and psychological wellbeing. Please include any relevant investigations.
* Please complete the sections below on social circumstances and functional status
# Includes e.g: Citizens Advice, Carer Support, Age Concern, Advocacy, Disease Group (please specify need)
MEDICAL CONDITIONS e.g. Diabetes etc.
MEDICATIONS
Drug Dose Freq. Route
………………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………..
ALLERGIES / ADVERSE REACTION TO PREVIOUS MEDICATION
*SOCIAL CIRCUMSTANCES
Does the person care for somebody? Yes  No 
Is the person housebound? Yes No 
Issues with: Dressing  Washing  Cooking 
Existing care package  (please give details)
Other……………………………………………………………………………………………………………………………………………………………...
*FUNCTIONAL ISSUES (relating to the reason for referral)
Walking Aid Assessment 
Mobility Assessment 
Pain Acute 6/52 
Chronic > 6/52 
Falls (include date / frequency / cause )  / Assessment of function relating to ADL  Advice re: self-management 
Swallowing 
Communication 
Other …………………………………………………......
REFERRER DETAILS
Name of Referrer: Tel.No:
Date of Referral: Time of Referral:
Referrer Signature:
Virtual Ward Referral Guidance
VIRTUAL WARD System
PRO-ACTIVE NURSING
Pro-active Care Programme - 12 week tailored program. Starting with holistic common assessment the team then focus on optimisation of LTC, medicine concordance, baseline screening care planning, education, self-care and behavioural change. Involvement with therapists and specialist teams as deemed necessary.
Medication Management - Patient centred focus on medication including liaison with dispensing pharmacist
Disease Monitoring - as per GP requirements (please specify specifics)
Healthy Living Review - a screening review aimed at practice non-attenders over 65y. Baseline screening, observations and bloods tests
Palliative Care - standard district nurse input linking with community palliative nurses, macmillan and hospice at home as required
Wound care - as required
Health Education - as required
RE-ABLEMENT
As per referral to specified discipline. Other professionals will be involved however depending on the result of the initial assessment

Bootle Virtual Ward Seaforth/Litherland

Telephone Number: 0151 247 6004 Fax: 0151 922 2890 Telephone Number: 0151 928 8255 Fax 0151 928 8241

Practice / Practice
Dr Goldberg / Dr Choudhary, N
Dr Misra / Dr Dilworth, A & Partners
Dr Morris & Ptners / Dr Goldberg, D
Dr Pitalia (Orrell Lane) / Dr Fraser / Halstead
Dr Pitalia (Rawson Road) / Litherland PC WI Service
Dr Roberts & Ptners / Dr McElroy, C & Thompson T
Dr SrivastavaPtners / Dr Sapre, S, (Aintree Road)
Dr Stanley & Partners / Dr Taylor, N
Dr Stephenson, SJ & Ptners,(BootleVillage Surgery) / Dr Vickers & Partners, (Bridge Road Medical Centre)
Dr Williams, N & Partners

Crosby Virtual Ward Maghull Virtual Ward

Telephone Number: 0151 247 6342, Fax: 0151 924 0035 Telephone Number: 0151 531 0228 Fax: 0151 531 1186

Practice / Practice
Crosby Village Surgery / Dr Coulter, SW
Crossways SSP Practice (Dr Sharma) / Dr Sapre / Dr Griffiths
(Maghull Family Surgery)
Dr Doran, CL & Partners / Dr Thomas, B & PJ
Hightown Village SSP Practice / Dr Thomson, C & Partners, (High Pastures)
Dr Hughes, MI & Partners / Dr Wray & Partners, (Westway)
Dr Shaw, CR & Partners
Thornton SSP Practice
Dr Tong, N & Partner
Dr Vitty, F & Partners

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