Patient Referral - Medical
21 Old Stellenbosch Road, Somerset West. Tel: 021 852 4608. E-Mail: nursing@helderberghospice.org.za
Helderberg Hospice - Medical Request for Referral
This form is for the medical practitioner to complete. We require ALL of the information in order to fully assess the patient's suitability for Hospice Services. Please note that, as a Non-Profit Organisation, our service capacity is sometimes limited and, it may not always be possible to accept all patients onto service immediately and, where appropriate, the admission may be deferred for a period of time or referred to an alternate institution for further suitable care or support. Once we receive your completed medical referral request form, we promise to get back to you within 48 working hours to advise you of the status of your referral. Should the information provided be insufficient for us to make a determination around suitability for service, we will request further information from the patient, the patient's family or the patient's care team. In these instances, it may take a further 48 working hours to finalise an admission. In any event, you can expect a referral for admission to take between 2 to 4 working days. Please note that we do not process referrals for admissions, of new patients, on weekends or public holidays.
Date on which this form is being completed
*
-
Month
-
Day
Year
Date
Name of the person completing this form
*
First Name
Last Name
E-mail address of the person completing the referral form
*
example@example.com
Section A: Patient's Information
(to be completed by either the treating medical practitioner or the patient or the patient's family member)
Patient's Name
*
First Name
Last Name
Patient's Identity Number
*
Patient's Gender
*
Please Select
Male
Female
Gender Neutral
Patient's Primary Phone Number
*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Patient's Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Section D: Patient's Care Team Information
To be completed by either the treating medical practitioner. Please note that there are portions of this section that require the treating medical practitioner sign acknowledgement of care - please only sign this acknowledgement if you are the treating medical practitioner concerned.
Who is currently leading the patient's care team?
*
Private Doctor
State Doctor
Patient's Hospital Folder Number (required for State Patients)
Name of PRIVATE Practitioner who is leading the patient's care team:
*
First Name
Last Name
Phone Number of Practitioner who is leading the patient's care team:
*
Please enter a valid phone number.
E-mail Address of Medical Practitioner
example@example.com
Name of Specialist Practitioner (e.g. Oncologist)
First Name
Last Name
Phone Number of Specialist Practitioner (e.g. Oncologist)
Please enter a valid phone number.
E-mail Address of Specialist Practitioner (e.g. Oncologist)
example@example.com
Additional Clinical Notes / X-Rays / Scans - DOCUMENT
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Name of Patient's Medical Aid Scheme (where applicable)
D.1 - If the patient is a PRIVATE patient or covered by a MEDICAL AID SCHEME, the referring medical practitioner must agree to be available and remain responsible for the day to day oversight of the patient whilst they are in Hospice Care. Do you, as the medical practitioner, agree to avail yourself for this purpose?
*
YES
NO
Important Notice
If you have answered "NO" to D1 above, please note that Helderberg Hospice will NOT be able to accept your patient referral. You will be able to complete the referral forms and SUBMIT for review, however, It is a requirement for admission to our service that all private and medical aid scheme patients remain under care from their referring medical practitioner for the duration of their admission to our service unless the patient is appropriately referred to a colleague private to admission to our practice. If you are completing this referral as a Medical Practitioner on behalf of a State subsidised patient, you do not need to stand cover for the patient as State Subsidised Patients are covered by our practice Medical Officer whilst in our care.
Signature of the Medical Practitioner who is currently responsible for the patient and, where the answer to D1 above was YES, this is also the medical practitioner who will accept clinical responsibility for the patient whilst in Hospice Care.
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Section D: Medical Diagnosis of the Patient
To be completed by either the treating medical practitioner. It is imperative that this section contains accurate and comprehensive medical information in order for Hospice to fully assess the patient's needs and to allow us to quickly and accurately allocate Hospice resources to the patient - it is preferable that this section is completed by the medical professional who is most knowledgeable with the patient's condition.
Primary Illness
*
If cancer: primary focus
If cancer: secondary sites / deposits
Additional illnesses including chronic illnesses
ICD 10 code/s (if you know this information)
Category of care required
*
Please Select
Early Diagnosis
Palliative Care
Terminal Care
Reason/s for Hospice Referral (mark more than one option if applicable)
*
General Palliative Care
Symptom Control
Pain Management
Respite Care
Terminal Care
Other
If answered Other to the above question, please state the reason below:
What is the patient's current mobility status?
Please Select
Walking / mobile
Mobile with assistance / walker / crutches etc...
Bed bound / immobile
Please list below any relevant medical interventions undertaken to date, including surgical procedures
Has the patient received Radiation Therapy for their illness?
*
YES
NO
I DON'T KNOW
Has the patient received Chemo Therapy for their illness?
*
YES
NO
I DON'T KNOW
Has the patient received Hormone Therapy for their illness?
*
YES
NO
I DON'T KNOW
Please list the Patient's current medications - including Name, Strength and Dosage
*
Does the Patient suffer from any medicine idiosyncrasies or allergies?
*
YES
NO
I DON'T KNOW
If answered YES to the above, please list below:
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Personal Information
By providing Helderberg Hospice with patient personal information and documentation, as set out herein, you voluntarily consent to it being reasonably retained, stored and processed. Your further acknowledge that such information is retained and processed for the lawful purposes and objectives of the organisation and that the information may be retained in a database to allow the organisation to communicate with you in future regarding prospective objectives / donations / interests. Such personal information will remain confidential and will not be shared with any third parties without your consent. All reasonable measures will be taken to safeguard your personal information. Should you object to our retention and processing of your personal information or should you wish to rectify your personal information retained with us, kindly inform us via e-mail at data@helderberghospice.org.za
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