Get the free PALLIATIVE CARE INTAKE REFERRAL FORM

(Form CC025)PALLIATIVE CARE INTAKE REFERRAL FORM An assessment by the palliative care staff will ensure all critical clinical information is communicated and aims to develop a management plan that

How to fill out palliative care intake referral

How to fill out palliative care intake referral

1. Obtain the appropriate intake referral form from the palliative care program.
2. Fill out the patient's personal information, including name, date of birth, and contact details.
3. Provide information about the patient's medical history, current diagnosis, and treatment plan.
4. Include details about the patient's symptoms and any pain management needs.
5. Specify any goals of care or preferences for palliative care services.
6. Obtain necessary signatures, such as from the patient or their healthcare proxy.
7. Submit the completed intake referral form to the palliative care program for review.

Who needs palliative care intake referral?

1. Patients with serious illnesses such as cancer, heart failure, chronic obstructive pulmonary disease (COPD), or advanced dementia.
2. Patients experiencing symptoms such as severe pain, shortness of breath, fatigue, nausea, or loss of appetite that are not adequately controlled with standard treatments.
3. Patients who would benefit from a holistic approach to care that focuses on symptom management, psychosocial support, and coordination of care.

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What is palliative care intake referral?

Palliative care intake referral is a process of referring a patient to palliative care services to address their physical, emotional, and spiritual needs.

Who is required to file palliative care intake referral?

Healthcare providers, including physicians, nurse practitioners, or social workers, are required to file palliative care intake referrals.

How to fill out palliative care intake referral?

To fill out a palliative care intake referral, healthcare providers need to complete the necessary forms with the patient's medical history, current symptoms, and treatment goals.

What is the purpose of palliative care intake referral?

The purpose of palliative care intake referral is to ensure that patients with serious illnesses receive comprehensive care to improve their quality of life.

What information must be reported on palliative care intake referral?

Information such as patient demographics, medical history, current symptoms, treatment options, and any advance directives must be reported on a palliative care intake referral.