St Andrew’s Hospice Inpatient Referral Form
Henderson Street, Airdrie, ML6 6DJ Telephone: 01236 766951
Inpatient Referrals are reviewed Monday – Friday mornings; if the Patient requires an emergency admission please call the Hospice switchboard and ask for the on-call Doctor. Once complete – please email to standrewshospice.referral@nhs.net

1.Personal Details
Surname	Forenames
Address
Postcode	Telephone Number
Gender	Male	Female	Ethnicity
Age	CHI number
Date of Birth	/ /	Relationship status
Has the patient given consent for the referral?	Yes	No	If No, does the patient lack capacity? (Adult with Incapacity (Scotland) Act 2000)	Yes	No
If the patient lacks capacity, has a Certificate of Incapacity been completed?	Yes	No
Has the patient been provided with written information about the Hospice?	Yes	No	Information Booklets are available from the Hospice or can be viewed or downloaded from Hospice website.
Does the Patient Smoke?	Yes	No	Have you made the patient aware of the No Smoking Policy at the Hospice?	Yes	No

2.Contact Details
Name of Next of Kin	Relationship to Patient
Address
Postcode	Home Phone number
Does the patient live alone?	Yes	No	Mobile Phone Number
Is the Next of Kin aware of the referral?	Yes	No	Who should initial contact be with?	Patient	Next of Kin
Name of General Practitioner	Address
Post Code
Contact Number	Email Address

3.Current Care
Is the patient known to St Andrew’s Hospice?	Yes	No	Staff or Service Name (If Known)
Where is the Patient currently?	Other:
Complete this section if the patient is currently in Hospital
Hospital Name:	Under the Care Of:
Ward Name:	Contact Number:
Does the patient currently have the services of any of the following?:	Hospital Palliative Care Nurse	Community MacMillan Nurse	District Nurse	Other Nurse Specialist
Name of Nurse
Contact Details
Give details of any current Care Package
Social Work Contact	Telephone No:

4.Principle Reason for Inpatient Referral (Please Select)
Symptom Control	Rehabilitation	End of Life Care

5.Medical Information Please note medical staff at St Andrew’s Hospice do not have ready access to patients Hospital or Community Notes
Main Diagnosis	Date of Diagnosis
Indications of Advanced Disease: (e.g. metastatic disease, performance status, O2 dependence, etc.)
Past Medical History :
Relevant Investigation Results:
Does the patient currently have a DNACPR in place?	Yes	No	Additional info about DNACPR Discussions :
Has the patient been fitted with a pacemaker?	Yes	No	Does the patient have any radioactive implants?	Yes	No
Has the patient ever tested positive for MRSA?	Yes	No	Additional information about MRSA history:
Is the patient aware of their diagnosis?	Yes	No	Are the patients family/next of kin aware of the diagnosis?	Yes	No
Is the patient aware of their likely prognosis?	Yes	No	Are the patients family/next of kin aware of the likely prognosis?	Yes	No
Mobility- please describe the patients level of mobility	Independently mobile	Mobile with a walking aid	Mobile with assistance	Immobile
Allergies or Intolerances	Medicines	Food	Other

Relevant Treatments or Interventions (e.g. surgery, radiotherapy, systemic anti-cancer therapy, NIV, PEG, etc)
Current Clinical Issues
Current Family/Social Issues Relevant to this Referral

6.Current Symptoms
None	An Occasional Problem	Moderate Problem	Severe Problem	Very Severe (Can’t Think Of Other Matters)	Cannot Be Assessed
Pain
Nausea/Vomiting
Dyspnoea
Bowel Disturbance (please describe below)
Confusion
Patient Distress
Family Distress
Other symptom information

7.Current Medication
Medicine	Dose	Frequency/prn	Date Commenced	Indication	Response (if relevant)
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Other Relevant Medication History

8.Room Requirement/Preference St Andrew’s Hospice has a limited number of single rooms. Clinical need or personal preference for a single room may delay admission to the hospice
Does the patient have a clinical need for a :	Single Room?	Multi Occupancy?	Please state clinical need:
Does the patient have a personal preference for a :	Single Room?	Multi Occupancy?	Please state personal reason:

9.Referrer Information Referrals will not be considered without GP (Community Patients) or Consultant (Hospital Patients) permission
Has GP/Consultant approval been given for this referral	Yes	No	Name of GP/Consultant
Name of Referrer
Designation
Address
Telephone Number
Mobile Telephone Number
Email Address
Date of Referral

(For Office use only)
Patient referral registered on CrossCare	Date / /	Patient known to Hospice/Notes available?	Yes	No
Patient Presented at Daily Admission Meetings	Date / /
Outcome	Added to Waiting List	Offered Bed	Inappropriate referral	Other(Please state)