Get the free PALLIATIVE CARE COMMON REFERRAL FORM UPDATE/REPORT:

Palliative Care Common Referral Form PALLIATIVE CARE COMMON REFERRAL FORM UPDATE/REPORT: Individual s Last Name: Health Card Number: Date of Birth: (DD/MM/BY) Current location: Home First Name: Version

How to fill out palliative care common referral

How to fill out a palliative care common referral:

1. Gather all necessary information: Before starting to fill out the referral, make sure you have all the required information about the patient. This includes their personal details, medical history, current diagnosis, and any specific medical needs they may have.
2. Identify the referring healthcare professional: Indicate the name and contact information of the healthcare professional who is making the referral. This could be a primary care physician, a specialist, or a nurse practitioner.
3. Specify the reason for the referral: Clearly state the reason why the patient is being referred for palliative care. This could be due to a terminal illness, uncontrolled symptoms, or the need for pain management and support.
4. Include supporting documentation: Attach any relevant medical documentation that supports the need for palliative care. This could include medical reports, test results, imaging studies, or treatment plans.
5. Provide a brief summary of the patient's condition: Write a concise summary of the patient's current condition, including their symptoms, treatment history, and any challenges they may be facing. This helps the palliative care team understand the patient's needs better.
6. Specify the desired outcomes: Clearly state what the referring healthcare professional hopes to achieve through the palliative care referral. This could include goals such as pain management, improving quality of life, providing emotional support to the patient and their family, or facilitating end-of-life planning.

Who needs a palliative care common referral?

1. Patients with terminal illnesses: Palliative care is often recommended for individuals with terminal illnesses such as cancer, advanced heart or lung disease, neurodegenerative disorders, or end-stage organ failure. These patients can benefit from the pain and symptom management, emotional support, and coordinated care provided by a palliative care team.
2. Individuals with uncontrolled symptoms: Palliative care can also be appropriate for patients who are experiencing uncontrolled symptoms related to their medical condition, such as severe pain, nausea, shortness of breath, anxiety, or depression. The expertise of a palliative care team can help address these symptoms and improve the patient's overall well-being.
3. Those requiring end-of-life care planning: Patients who require assistance with end-of-life care planning, including advance care directives, hospice care, or discussions about treatment preferences, may benefit from a palliative care referral. Palliative care teams can provide guidance, support, and resources for these important discussions.

In summary, filling out a palliative care common referral involves gathering necessary information, identifying the referring healthcare professional, specifying the reason for the referral, including supporting documentation, providing a summary of the patient's condition, and stating desired outcomes. Palliative care referrals are typically made for patients with terminal illnesses, those with uncontrolled symptoms, and individuals requiring end-of-life care planning.

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