Palliative Care Consult Referral Palliative Care Consult Referral Form Step 1 of 2 50% 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 AM/PM Job Title * Required Organization Name, Unit/Floor * Required City/Area * RequiredBrampton, Caledon, Malton and Dufferin: Rhonda McGuireBurlington, Milton and Halton Hills: Amanda SpurrellEast Mississauga: Lia MusettiWest Mississauga, Oakville: Villy SimonettaPhone Number and Extension * Required Email 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 Allergies * RequiredName of Most Responsible Physician (MRP) and/or NP Involved * Required SituationIn your opinion, would you be surprised if the patient/resident were to die in the next 12 months? * Required Yes No See Early ID GuideIs the patient/resident receiving a palliative approach to care? * Required Yes No Appropriate for any individual and their families who are facing issues associated with life-limiting illness to improve their quality of life at any stage.Brief description of situation/issue(s): * RequiredBackgroundDiagnose(s) (life-limiting condition(s)) and relevant medical history * RequiredPalliative Performance Scale (PPS) * Required100%90%80%70%60%50%40%30%20%10%See PPSHas there been a recent change in PPS? * Required Yes No Presenting symptom(s)/issues: * Required Pain Other symptom Other concern (i.e. family care conference) AssessmentASSESSMENT: * Required Cognitively Intact Cognitively Impaired O: Onset When did it begin? How long does it last? How often does it occur? See Onset GuideP: Precipitating & Alleviating Factors What brings it on? Makes it better? Worse?Q: Quality What does it (pain) feel like?R: Region & Radiation Where is it (the pain)? Does it (the pain) spread anywhere?S: Severity What is the intensity of this symptom? Is a pain/symptom rating scale being used (e.g. on a scale of 0 to 10 with 0 being none and 10 being worst possible)? Average, worst, best scores? How bothered are they by this symptom?T: Timing/Treatment Current treatments and efficacy? Timing of symptom?U: "How is the pain affecting you?" What does the person believe is causing this symptom? How is it affecting them? V: Values - What is the acceptable level for this symptom? What is the person’s comfort goal or acceptable level for this symptom?Assessment Tool Used:PainADAbbeyPACSLACNone of the AboveOther Assessment Tool Used: *Cognitively Impaired OnlyMost recent scores from observational tool used (e.g. PainAD) and dates completed:*Cognitively Impaired OnlyResults of physical assessment, relevant lab tests and imaging (X-Rays, CT, MRI, etc.) and please include dates completed:Any other results/findings of assessment:*Cognitively Impaired OnlyIs DOS being utilized? * Required Yes No Additional information related to concern(s):Upload e-MAR here (recommended), or manually enter relevant medications for pain and/or symptom management below.Max. file size: 40 MB.Relevant Medications for Symptom Control (Click + to add additional line)MedicationDosageRouteTimes Given RecommendationWhat would your suggestions be?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
