ST PETER’S HOSPICE

DIRECT HOSPICE AT HOME REFERRAL FORM

Charlton Road, Brentry, Bristol BS106NL

Tel: 0117 915 9508 Fax: 0117 9811405

Email:

Surname:
Fore name:
Title:
D.O.B:
Marital status:
Address:
Postcode:
Tel No:
Mob No:
NHS No:
Occupation:
Religion:
Ethnic Group: / Next of kin:
Name:
Relationship:
Address:
Postcode:
Tel no:
Mob no:
Main carer:
Address (if different):
Please indicate all members of the household
Name: Relationship to Patient:
If in hospital, which ward please and contact number:
PROFESSIONALS INVOLVED IN CARE
Name / Address / Phone / Out of Hours Numbers
District Nurse / AGREED TO referral to H@H?
Yes □ No □
G.P. / AGREED TO referral
to H@H?
Yes □ No □
PCHSS / Aware of referral
to H@H?
Yes □ No □
CHC / Has a referral been made to CHC? Contact details; / Aware of referral
to H@H?
Yes □ No □
Other / e.g Marie Curie, If so what shifts have been booked?
Is the patient known to St Peters Hospice:
Yes □ No □ / If yes, Who is the Community Nurse?

HOME ENVIROMENT

Accommodation / House□ / Bungalow□ / Flat□ / Warden Controlled□ / Other □
Detail any Problems with access / e.g. parking, key safe details
Safety Factors / Are there any smokers in the home?
Yes □ No □ / Are there pets in the home?
Yes □ No □
Problems with comfort / Is there lack of adequate facilities eg. Heating, cleanliness?

MEDICAL DETAILS

Primary Diagnosis:
Date of Diagnosis: / Known Metastases:
Other Medical Conditions: / Adverse Drug Reactions:
Pacemaker: Yes□ No □
Consultant(s): / Hospital: / Hospital number:
Current Medication: / Medication sent home with patient: / G.P. Authorisation sheet in the home?
Yes □ No □
End of Life drugs prescribed?
Yes □ No □
Current Health Problem (In addition to above)
Current mobility:
Can the patient move independently or with assistance?
What equipment is in situ or on order ? e.g hospital bed, slides sheets.
Hygiene needs and continence:
Please indicate if the patient has a catheter, or wears incontinent pads
Eating/drinking:
Is the patient eating and drinking? Any special dietary problems? Any problems with swallowing?
Routes of medication:
Please indicate if help is needed to take medication. Is there a syringe driver box in the home?
Communication:
Please indicate any difficulties with communication
Alertness:
Please indicate if the patient is confused, agitated, drowsy, etc
Nursing needs:
Please describe nursing care needs e.g dressings
Night time needs:
Please indicate any variance in care needs overnight
Any other important information:
Details of any uncontrolled symptoms, spiritual/cultural needs, carer needs
Is the patient aware of prognosis?
Yes □ No □ / Is the family aware of prognosis?
Yes □ No □
Has the H@H service been explained to the family?
Yes □ No □ / Has patient/family agreed to this referral?
Yes □ No □
Do Not Attempt Resuscitate (DNAR) Form In Home
Yes □ No □

REFERER

Signed:…………………………………….……. Designation:……………….……………………......

Location:………………………………………... Tel No:…………………………… Mob No:………………………………….

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