Get Form Palliative Care 2020-2025

This guide provides clear and concise instructions for completing the Form Palliative Care online. It is designed to assist individuals in accurately filling out all necessary components while ensuring that the process is straightforward and user-friendly.

Follow the steps to complete the Form Palliative Care efficiently.

1. Click 'Get Form' button to access the form and open it in your preferred document editor.
2. Begin with the patient details section. Enter the patient's full name, date of birth, gender, address, phone number, and mobile contact. Ensure all information is accurate and current.
3. Indicate whether the patient possesses a medical card and if they have health insurance. Provide the patient's current location for service coordination.
4. Fill out the contact person section with the name, address, relationship to the patient, and phone number of the designated family member or friend.
5. Specify if the patient is living alone by selecting ‘Yes’ or ‘No’. This information may be pertinent for service planning.
6. Select the urgency of the referral, noting that it may be subject to triage by the Specialist Palliative Care Team. Options may include hospice admission, community-based services, hospital outpatient department, or other, along with the expected response time.
7. Provide details about the patient's diagnosis, treatment to date, and any further treatment planned. Attach recent correspondence, imaging reports, and blood results if applicable.
8. List active problems or reasons for the referral and include any other medical conditions or infection control issues, such as MRSA.
9. Document current medications, their dosages, and any significant recent changes. Also, include known allergies or drug side effects the patient may have.
10. Select the appropriate performance status that best describes the patient's capabilities regarding self-care and activity levels.
11. Estimate prognosis in days, weeks, or months and confirm awareness of the diagnosis among the patient and family.
12. Include any other relevant information, such as additional contact details, family issues, or the need for an interpreter.
13. Complete the consultant and referring general practitioner information, including their name, phone number, job title, and address. Confirm that the GP is aware of the referral.
14. Finally, review all entries for completeness and accuracy. Save your changes, download the completed form, and print or share it as necessary.

Complete your Form Palliative Care online today to ensure timely and accurate referrals.