Palliative Care Consult Referral Palliative Care Consult Referral Form Step 1 of 3 33% Health Care Provider (HCP) Making ReferralName of Person Referring * Required First Last Preferred Date to Contact - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Preferred Time to Contact * Required : Hours Minutes AM/PM AM PM Job Title * Required Organization Name * Required City/Area * RequiredBramptonBurlingtonCaledonDufferinHalton HillsMaltonMiltonEast MississaugaWest MississaugaOakvillePhone Number and Extension * Required Email * Required Alternate Contact Information at HCP First Last Job Title Phone Number and Extension Email Patient/Resident InformationPatient/Resident Name * Required First Last Date of Birth - must be dd/mm/yyyy format * Required DD slash MM slash YYYY Age * Required In your opinion, would you be surprised if the patient/resident dies in the next 12 months? * Required Yes No Is the patient/resident receiving a palliative approach to care? * Required Yes No Palliative Performance Scale (PPS) * Required100%90%80%70%60%50%40%30%20%10%Diagnose(s) * RequiredAllergies * RequiredName of Most Responsible Physician (MRP) and/or NP Involved * Required Relevant Medications for Symptom Control (Click + to add additional line)MedicationDosageRouteTimes Given Optional: Upload a Medical Administration Record (MRP) or Medication ListMax. file size: 40 MB. SBAR Communication ToolSITUATION: The complex problem/symptom is: * RequiredBACKGROUND: State the Pertinent medical history/any recent trauma: * RequiredGive a brief synopsis of the treatment to date and effectiveness: * RequiredASSESSMENT: * Required Cognitively Intact Cognitively Impaired O: Onset *Cognitively Intact OnlyP: Precipitating & Alleviating Factors *Cognitively Intact OnlyQ: Quality of Pain *Cognitively Intact OnlyR: Region & Radiation *Cognitively Intact OnlyS: Severity *Cognitively Intact OnlyT: Timing/Treatment (Current medications for symptoms) *Cognitively Intact OnlyU: "How is the pain affecting you?" *Cognitively Intact OnlyV: Values - What is the acceptable level for this symptom? *Cognitively Intact OnlyAssessment Tool Used:PainADAbbeyPACSLACNone of the AboveOther Assessment Tool Used: *Cognitively Impaired OnlyResults/Findings of Assessment*Cognitively Impaired OnlyIs DOS being utilized? * Required Yes No RECOMMENDATIONS: What would your suggestions be?Results of relevant lab tests and imaging (X-Rays, CT, MRI, etc.) & please include dates completedAny other thoughts/concerns?ConsentAcclaim Health is committed to individual privacy and has taken reasonable precautions to ensure the security of the information you are submitting through this online form. By clicking "I agree" you are acknowledging and accepting the potential risks inherent in submitting personal information and/or personal health information online. Please contact us by telephone at 905-827-8111 if you do not wish to submit this information online and we will be happy to assist you. I agreeCAPTCHA
