First Name: / Referred phone number:
Address: / Consultant (1): / Oncologist/Consultant (2):
Post Code: / GP:
Address:
Telephone:
D.O.B.:
Hospital Number: / Postcode:
CHI. Number: / Tel No:
Next of kin: / Diagnosis:
Relationship to patient: / Date of Diagnosis:
Contact No. / Secondary Sites:
Religion: / Date of Diagnosis:
Ethnicity: / For non cancer diagnosis, please give brief history:
Previous treatments:
Describe patient’s understanding of disease and prognosis:
Is patient aware of referral? Yes □ No □
Has Consultant / GP agreed to and is aware of referral? Yes □ No □
Have relatives been told of diagnosis: Yes □ No □ Relatives aware of referral: Yes □ No □
Any other relevant information? (e.g. current or planned treatment):
Co-existing medical conditions/past medical history:
Allergies:
North and East Glasgow Palliative Care Services – Referral Form Part 2
Patient’s name: Hospital No: D.O.B:
Patient currently at:
Home □ Care Home: ______Tel No: ______
Hospital: GRI □ Stobhill □ BOC □ Other □ Ward:______Tel No: ______
Is District Nurse in attendance? Yes □ No □ Name: Tel No:
Reason for referral or any additional information:
Please tick the appropriate box depending on the severity of symptoms on the following chart:
Symptoms / None / Mild / Moderate / Severe
0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10
Pain
Breathlessness
Agitation or confusion
Constipation or diarrhoea
Nausea & vomiting
Spiritual distress: patient
Spiritual distress: family or carers
Inappropriate care environment
Other:
Other:
Which service is required? / Degree of urgency?
□ Day Therapy Unit Assessment / □Soon (3-7days) □Whenever possible (8-14days)
□ Hospital Review/Assessment / □ Same day(24hrs) □ Urgent (48hrs) □Soon (3-7days)
□ Symptom Control Clinic (Outpatient only) / □Soon (3-7days) □Whenever possible (8-14days)
□ Community Clinical Nurse Specialist / □Soon (3-7days) □Whenever possible (8-14days)
□ Domiciliary Medical Visit / □ Urgent (48hrs) □Soon (3-7days) □Whenever possible
(8-14days)
□ Admission to Marie Curie Hospice (HospiceAdmissions only, please score level of urgency in box)
1 = same day (24hrs) 2 = Urgent (48hrs) 3 = Soon (3-7 days) 4 = When bed available (8-14 days)
MC-PAT© (Marie Curie Priority for Admission Tool) level of Urgency :
Please state if Patient would prefer Single Room: YES NO
Signature:
Print Name: / Date: / Designation:
Email referral form to:
Referral Advice for Health Care Professionals
We offer specialist care, free of charge for people living with a terminal illness and provide support for their families.
We accept referrals for:
- Management of complex physical symptoms
- Management of complex emotional / spiritual distress
- Multidisciplinary Team (MDT) assessment and rehabilitation
- End of life care
All new Referrals to our services are assessed and passed to the appropriate service from our morning clinical meeting. Admissions to the inpatient unit are reviewed and prioritised based on need at this morning meeting.
Please ensure that all necessary clinical and social information is provided on the referral forms so as to ensure that patients are seen by the service that will best meet their needs.
Referrals by GPs and district nurses
GPs and district nurses should refer electronically via SCI Gateway by selecting “Palliative Care Services GG&C” on the referral destination and following the step-by-step prompts thereafter in the “palliative services” and “clinical data” tabs.
Referral guidance for palliative care services can bedownloaded here.
If SCI Gateway cannot be used, please follow the instructions for the acute sector and all other referrers.
Acute sector and all other referrers
Hospital Palliative Care Teams if possible should refer via SCI Gateway. If not available and for all other teams in Acute services, please complete Marie Curie referral form which can be downloaded here
Completed referral forms should be submitted whenever possible by secure email to
Fax and postal referrals should be avoided to ensure that referrals are triaged as quickly as possible and patient sensitive information is shared in accordance with Caldicott guidelines. However, if essential, a referral form can be faxed from a secure line to the hospice clinical fax number 0141 557 7429
Postal referrals must be marked private and confidential for the attention of a designated clinician.
Advice regarding referral is available during office hours from the Marie Curie Hospice Patient Coordinator on 0141 5577400
Urgent referrals
Urgent referrals can bemade by telephone to 0141 5577400 during and outwith office hours. If an emergency (same day) admission is being requested, please ask for the Doctor on Call ( 9am- 5pm) or the Contact Nurse ( out of hours). Please send a completed referral form as soon as possible using the recommended routes
Revised January 2017