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Home » Palliative Care Consult Referral

Palliative Care Consult Referral

Palliative Care Consult Referral Form

"Required" indicates required fields

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Email

This field is for validation purposes and should be left unchanged.

Health Care Provider (HCP) Making Referral

Name of Person ReferringRequired

First Last

Preferred Date to ContactRequired

MM slash DD slash YYYY

Preferred Time to ContactRequired

Hours

:

Minutes

AM/PM AM/PM

Job TitleRequired

Organization Name, Unit/FloorRequired

City/AreaRequired

Phone Number and ExtensionRequired

Email

Alternate Contact Information at HCP

First Last

Job Title

Phone Number and Extension

Email

Patient/Resident Information

Patient/Resident NameRequired

First Last

Date of BirthRequired

DD slash MM slash YYYY

AgeRequired

Languages Spoken

AllergiesRequired

Name of Most Responsible Physician (MRP) and/or NP InvolvedRequired

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 historyRequired

Palliative Performance Scale (PPS)Required

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: 256 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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