REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
SUPPORTIVE AND SPECIALIST PALLIATIVE CARE CLINIC
Correspondence template for new referrals and existing patients

SEND TO 
Dr Andrew Broadbent (Community Palliative Care)
Supportive and Specialist Palliative Care Service
Phone 1300 763 218
Fax 07 5668 6759                          

	FROM <DrName>
<Practice>
<UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Email: <PracEmail>
Provider Number: <DrProviderNo>	

If the matter is urgent please telephone the community CNC on 1300 763 218 or the on-call consultant on 5668 6000 if the patient requires admission

<TodaysDate>

Dear Dr Broadbent

SECTION 1 Patient details

RE: <PtFullName>
DOB: <PtDoB>
AGE: <PtAge>

Gender: <PtSex>
Address: <PtAddress>
Home Ph: <PtPhoneH>
Mobile Ph: <PtPhoneMob>
Medicare Number*: <PtMCNo> (*Medicare ineligible patients will incur a consultation fee)	Next of Kin/Alternative Contact: <NOKName>
Next of Kin/Alternative Contact Ph: <NOKContact>
Does patient identify as Aboriginal and/or Torres Strait Islander: <Does pt identify as Aboriginal/Torres Strait Islander>
Interpreter required: <Interpreter required>
If yes, specify language: <If yes, specify language>	

Patient/decision maker agreeable to palliative care referral: <Is the patient/decision maker agreeable to referral>
What is the patient's current location: <What is the patient's current location>

SECTION 2 Reason for referral and additional clinical information

What is the reason for this referral: <Specify main reason for referral>
Please provide provisional diagnosis (if available): <Provisional diagnosis if available>
Please include any symptoms and date of onset (if known): <Symptoms and date of onset if known>
Paste or type relevant history, clinical examination findings and treatment to date if required

Assessment and provision of service: <Reason for ref: Assessment & provision of service>
If yes, please specify: <If yes, specify assessment and service details>
To set or achieve care goals: <Reason for ref: To set or achieve care goals>
If yes, please specify: <If yes, specify goals of care details>
Patient needs exceed primary care capacity/resources: <Reason for ref: Patient needs exceed primary care>
If yes, please specify: <If yes, specify patient needs details>
Difficulty maintaining place of residence: <Reason for ref: Difficulty maintaining place of resid>
If yes, please specify: <If yes, specify patient needs details>
Care at the end of life requirements: <Reason for ref: Care at end of life requirements>
If yes, please specify: <If yes, specify care at end of life requirement details>

SECTION 3 Mandatory clinical information

Patient has cancer or other life limiting illness: <Patient has cancer or other life limiting illness>
If yes, please specify: <If yes, specify cancer or other illness details>
Estimated prognosis: e.g. days weeks months years: <Estimated prognosis: eg days weeks months years>
Are NGOs or allied health/other providers involved in current care: <Are AH/other providers/NGOs involved in care>
If yes, please specify: <If yes, specify providers involved in care details> 
Is there an Advanced Health Directive in place: <Is there an Advanced Health Directive in place>
If yes, please specify:<If yes, specify Advanced Health Directive details>
Does the patient have a Statement of Choices : <Does patient have a Statement of Choices>
If yes, please specify: <If yes, specify Statement of Choices details>
Does patient have an Enduring Power of Attorney: <Does patient have Enduring Power of Attorney>
If yes, please specify: <If yes, specify EPOA details>
Are you able to do home visits: <As the GP, are you able to do home visits>
If no, please specify barriers: <If no, specify barriers to home visits details>
Are you available to do teleconferences: <As the GP, are you available to do teleconferences>
If yes, please specify: <If yes, specify availability for teleconferences details>
SECTION 4 Investigations

Please attach any investigation relevant results regarding the disease and severity including blood tests, MRIs, CT and pathology results.

<Ix>
SECTION 5 Duration of referral

Please indicate how long you would like your referral to remain valid: <Duration of referral>

Indefinite referrals do not expire until the patient has been discharged by the hospital service. When referrals expire, there is an expectation that the referring GP or another GP will review the care of the patient. If the patient still requires specialist care, the GP will then be required to submit a new referral for ongoing care.  

SECTION 6 Social factors and impact on the patient

Consider the impact on activities of daily life; ability to care for others; personal safety/frailty; other factors. Please paste or type relevant information.

	

SECTION 7 Medical history including co-morbidities and previous surgical interventions

Alcohol: <AlcHx>
Smoking: <SmkStatus> <SmkHx>
<PMHAll>
Allergies: <Reactions>
Current prescribed medications: <CurrentRx>
SMOs/VMOs/CNCs in this Specialist Service

Dr Andrew Broadbent (Director)	Dr Joanne Doran	Dr Graham Grove	
Dr Nicola Morgan	Ms Julie Barnes (CNC)	Ms Jodie Morris (CNC)	
Ms Julie Murphy (CNC)	Ms Helen Gullison (CNC)