Get Palliative Care Form

Filling out the Palliative Care Form online can streamline the referral process for palliative care services. This guide aims to provide clear instructions to ensure that you complete the form accurately and efficiently, promoting effective patient support.

Follow the steps to successfully fill out the Palliative Care Form.

1. Click 'Get Form' button to obtain the form and open it in your browser.
2. Begin by entering the patient details, including their surname, first name, date of birth, and age. Make sure to confirm the patient’s consent for referral and whether the GP is aware of it.
3. Provide the patient's address and contact details, including telephone and mobile numbers, as well as the NHS number and hospital number if applicable.
4. Complete the section regarding the patient's primary diagnosis and any relevant history of disease and treatment, ensuring you use the guidance provided by the GSF Prognostic Indicators.
5. Fill in the Next of Kin or Patient Representatives section, including their contact information and relationship to the patient.
6. Indicate whether a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) is in place and if the community nursing team has been contacted.
7. Detail the reason for referral, selecting any applicable options related to complex pain, symptom control, social, psychological, or spiritual needs.
8. Specify the service requested, whether it be an assessment at home, in a hospital, or at a nursing home.
9. Answer questions regarding the patient's living situation, mobility, current medications, and any known drug sensitivities or allergies.
10. Complete the sections regarding the patient's awareness of their diagnosis and prognosis, as well as the awareness of the carer.
11. Finally, fill out the referrer’s name, signature, job title, contact number, and the date before saving your changes.
12. After completing the form, you can download, print, or share it as needed.

Complete your Palliative Care Form online today for efficient processing of care referrals.