Inpatient Referral Form - Teesside Hospice

Section 1: Patient Details

Patient's name

Date of birth (DOB)

NHS No

Patient's Tel No

Patient's main address including postcode

Has the patient consented to the referral? (If no, enter the reason)

Patient current location

Please state hospital / ward / care home

Marital status

Ethnic origin

Religion

Lives alone

GP Details

Identified risks to health professionals? (e.g. threats of violence, pets, safeguarding)

Patient diagnosis and PMH

Prognosis

Is the patient aware of prognosis?

Service Required

How soon is the service required?

Section 2: Carer Details

Main carer (name and relationship)

Main carer telephone number

Is NOK different to main carer? If so, please provide details

Section 3: Patient Information

Symptoms (please tick all that apply)

Pain

Nausea/vomiting

Constipation

Breathlessness

Agitation/restlessness

Psychological Distress

Poor mobility

Approaching end of life

Other (please state)

Severity of symptoms

Phase of illness

Karnofsky score

Discrepancy between care needs and care arrangements

Any extra information (tick all that apply)

Oxygen

Enteral feeding

Intravenous regime

Specialist equipment (e.g. Alt. Mattress / Bariatric bed)

NIV

Other (please state)

Patient's nutritional status

Enteral feeding

Has the patient got any swallowing problems? (YES / NO - please state)

Has the patient got any infections?

Please state the infection

Is the patient symptomatic of infection?

Advanced Care Planning

DNACPR

Respect form

EHCP

ADRT

LPA

Please provide details of LPA (Health or/and welfare – name of attorney)

Preferred place of Care

Preferred place of Death

Any other information

Section 4: Referral Details

Referred by (referrer's name)

Date of referral

Organisation or Department

Contact Tel No

Thank you for completing the referral. Please ensure this form is completed to the best of your knowledge – this will help us prioritise.

Please email this form to: stees.teessidehospice.cas@nhs.net
Urgent referrals: please ring the inpatient unit on 01642 811061 as soon as possible.

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Inpatient Unit Referral Form

Section 1: Patient Details

Section 2: Carer Details

Section 3: Patient Information

Section 4: Referral Details

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