ࡱ>  <bjbjFF *$$ LL8 !d_w" ++++X. x13b^d^d^d^d^d^d^add^)3-^X.33d^v?++s_v?v?v?3++b^v?3b^v?v?W6Y0B`9~XY_0_X'ev?'e0Yv?Y333L :   Palliative Care Supplementary Information To assist workers/practitioners to communicate additional information required for palliative care referrals.Consumer Name:  FORMTEXT       Date of Birth: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT      Sex:  FORMTEXT       UR Number:  FORMTEXT       or affix label hereReferral Referral type  FORMCHECKBOX  1. To Community based service  FORMCHECKBOX  2. To inpatient service, for admission  FORMCHECKBOX  3. To inpatient service, for respiteInpatient details Name of hospital/facility:  FORMTEXT       Is the Client an Inpatient?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Ward/Clinic:  FORMTEXT       Reason for Admission:  FORMTEXT       Expected discharge date:  FORMTEXT      Specialist details 1. Name:  FORMTEXT       Profession/specialty:  FORMTEXT       Hospital/clinic Name:  FORMTEXT       Address:  FORMTEXT       Phone:  FORMTEXT       Fax:  FORMTEXT       Email:  FORMTEXT       Contact details for medical consultant Name:  FORMTEXT       Phone:  FORMTEXT      2. Name:  FORMTEXT       Profession/specialty:  FORMTEXT       Hospital/clinic Name:  FORMTEXT       Address:  FORMTEXT       Phone:  FORMTEXT       Fax:  FORMTEXT       Email:  FORMTEXT       Contact details for medical consultant Name:  FORMTEXT       Phone:  FORMTEXT      Additional medical history/treatment Primary Diagnosis (include histology if applicable):  FORMTEXT       Date of Primary Diagnosis dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT     Secondary Diagnosis:  FORMTEXT       Date of Secondary Diagnosis dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT     Additional medical history (refer to SCTT health conditions for recording medications) (attach relevant imaging, blood test results etc)  FORMTEXT      Karnofsky performance score: Date completed: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT       FORMCHECKBOX  100 Normal; no complaints; no evidence of disease  FORMCHECKBOX  90 Able to carry on normal activity; minor signs or symptoms  FORMCHECKBOX  80 Normal activity with effort; some signs of symptoms of disease  FORMCHECKBOX  70 Cares for self; unable to carry on normal activity or to do active work  FORMCHECKBOX  60 Requires occasional assistance but is able to care for most of needs  FORMCHECKBOX  50 Requires considerable assistance and frequent medical care  FORMCHECKBOX  40 In bed more than 50% of time  FORMCHECKBOX  30 Almost completely bedfast  FORMCHECKBOX  20 Totally bedfast and requiring extensive nursing care by professionals and/or family  FORMCHECKBOX  10 Comatose or barely rousableKey symptom issues  FORMCHECKBOX  Pain  FORMCHECKBOX  Tiredness  FORMCHECKBOX  Nausea  FORMCHECKBOX  Depression  FORMCHECKBOX  Anxiety  FORMCHECKBOX  Shortness of breath  FORMCHECKBOX  Drowsiness  FORMCHECKBOX  Appetite  FORMCHECKBOX  Wellbeing  FORMCHECKBOX  Constipation  FORMCHECKBOX  Diarrhoea  FORMCHECKBOX  Other:  FORMTEXT        Produced by the Victorian Department of Human Services, 2009This information collected by:PCSI Page 1 of 3Name:  FORMTEXT      Position/Agency:  FORMTEXT      Sign: Date: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT     Contact number:  FORMTEXT       Palliative Care Supplementary Information To assist workers/practitioners to communicate additional information required for palliative care referrals.Consumer Name:  FORMTEXT       Date of Birth: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT      Sex:  FORMTEXT       UR Number:  FORMTEXT       or affix label hereAdditional medical history/treatment (cont.) Current and planned treatment (including treatment regimens/plans if applicable, information about upcoming appointments and information about how much medication the patient is being discharged home with)  FORMTEXT      Advance care planning (client and family/carer understanding of palliative care, and discussions about topics including Not For Resuscitation (NFR), antibiotics, transfusions, radiotherapy. This may take a range of forms including): Advance Care Plan Completed?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Medical Power of Attorney Attached  FORMCHECKBOX  Yes  FORMCHECKBOX  No Not For Treatment order (eg refusal of treatment certificate) completed  FORMCHECKBOX  Yes  FORMCHECKBOX  NoClient/family awareness of diagnosis and prognosis Client awareness Diagnosis  FORMCHECKBOX  Yes  FORMCHECKBOX  No Comments:  FORMTEXT      Prognosis  FORMCHECKBOX  Yes  FORMCHECKBOX  No Comments:  FORMTEXT      Family/carer awareness Diagnosis  FORMCHECKBOX  Yes  FORMCHECKBOX  No Comments (specify individual family member/carer awareness and any related issues):  FORMTEXT      Prognosis  FORMCHECKBOX  Yes  FORMCHECKBOX  No Comments (specify individual family member/carer awareness and any related issues):  FORMTEXT      Multidisciplinary assessments Have any relevant assessments been carried out (e.g. aged care, physiotherapy, occupational therapy, social work, volunteer or other)?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoAssessmentAssessor NameAssessor PhoneNumberNotes FORMTEXT e.g. Aged Care FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Produced by the Victorian Department of Human Services, 2009This information collected by:PCSI Page 2 of 3Name:  FORMTEXT      Position/Agency:  FORMTEXT      Sign: Date: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT     Contact number:  FORMTEXT       Palliative Care Supplementary Information To assist workers/practitioners to communicate additional information required for palliative care referrals.Consumer Name:  FORMTEXT       Date of Birth: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT      Sex:  FORMTEXT       UR Number:  FORMTEXT       or affix label hereNursing care (e.g. peg feed, 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