Get the free PALLIATIVE CARE BED REFERRAL FORM

(Form revised: September 16, 2016) Page 2 Wound Care & Percutaneous Drains: ... Application needs to be sent to both CCC & Park wood Access. Author: Linda

How to fill out palliative care bed referral

How to fill out palliative care bed referral

1. Start by gathering all the relevant medical information of the patient, including their medical history, current diagnosis, and treatment plan.
2. Contact the palliative care facility or provider where you wish to make the referral and inquire about their specific requirements and documentation.
3. Obtain a palliative care bed referral form from the facility or provider, if applicable.
4. Fill out the referral form accurately and completely, providing all the necessary information about the patient, including their name, demographic details, and contact information.
5. Include relevant medical details in the referral form, such as the patient's current condition, symptoms, pain management needs, and any specific palliative care preferences.
6. Attach any supporting documents or reports that may be required, such as medical records, test results, or a copy of the patient's advanced care directive.
7. Ensure that the referral is signed and dated by the referring healthcare professional or authorized individual.
8. Submit the completed referral form and supporting documents to the designated contact person or department at the palliative care facility or provider.
9. Follow up with the facility or provider to ensure the referral has been received and processed. Maintain open communication to address any additional requirements or inquiries.
10. Once the referral has been accepted, coordinate with the palliative care facility or provider to arrange for the patient's admission and transfer, taking into account their preferences and necessary logistics.

Who needs palliative care bed referral?

1. Patients with advanced, progressive, or terminal illnesses who require specialized care to manage symptoms, improve quality of life, and provide support for physical, emotional, and spiritual needs.
2. Individuals who experience severe pain, discomfort, or distress due to their illness and could benefit from expert pain management and symptom control.
3. Patients who have expressed a preference for receiving end-of-life care in a palliative care setting rather than a traditional hospital or home-based care.
4. Families or caregivers who require assistance and respite care in meeting the complex needs of a patient with advanced illness.
5. Individuals or healthcare professionals who recognize the need for a multidisciplinary approach that addresses not only the physical symptoms but also psychosocial and spiritual aspects of care.
6. Patients who have exhausted other available treatment options and whose primary goal is focused on comfort, dignity, and maintaining the highest possible quality of life until the end of life.

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