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charitable registration #11928 4602 RR0001

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Home » Palliative Care Consult Referral

Palliative Care Consult Referral

Palliative Care Consult Referral Form

Step 1 of 2

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Health Care Provider (HCP) Making Referral
Name of Person Referring * Required
First Last
Preferred Date to Contact * Required
MM slash DD slash YYYY
Preferred Time to Contact * Required

: Hours

Minutes

AM/PM AM/PM
Job Title * Required
Organization Name, Unit/Floor * Required
City/Area * Required
Phone Number and Extension * Required
Email
Alternate Contact Information at HCP
First Last
Job Title
Phone Number and Extension
Email

Patient/Resident Information
Patient/Resident Name * Required
First Last
Date of Birth * Required
DD slash MM slash YYYY
Age * Required
Languages Spoken
Allergies * Required
Name of Most Responsible Physician (MRP) and/or NP Involved * Required
Situation
In your opinion, would you be surprised if the patient/resident were to die in the next 12 months? * Required
- Yes
- No
Is 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): * Required
Background
Diagnose(s) (life-limiting condition(s)) and relevant medical history * Required
Palliative Performance Scale (PPS) * Required
See PPS
Has 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)
Assessment
ASSESSMENT: * Required
- Cognitively Intact
- Cognitively Impaired
O: Onset

When did it begin? How long does it last? How often does it occur? See Onset Guide
P: 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:
Other Assessment Tool Used:

*Cognitively Impaired Only
Most recent scores from observational tool used (e.g. PainAD) and dates completed:
*Cognitively Impaired Only
Results 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 Only
Is 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)
Medication Dosage Route Times Given
Recommendation
What would your suggestions be?
Consent
Acclaim 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.
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Charitable Registration #: 11928 4602 RR0001
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