Hospital Consultant: Allergies: Prognosis Day/s Week/s Month/s Year/s Other significant conditions’ Primary diagnosis (main reason for referral) Referral Reason for the referral: Symptom control Psychological Support Terminal care Staff Carer Inpatient Unit Has an EOL care plan been created in Health Requested Specialist Community & Crisis Support Analytics? service(s) (SCCS) Hospice at Home (Not applicable to Nursing Home Residents) Please refer to OrangeLine our website for Other (Please state) Physiotherapy the list of /Occupational Therapy /Pastoral groups currently Care/Complementary Therapy /Family offered by the Support Services/Bereavement/ services listed Heart Failure Clinic under ‘Other’. These groups are held in Pemberton Place Current problems requiring specialist palliative care and input: Advanced care plan: Resuscitation status: Vulnerabilities/Specific Needs If none listed, no vulnerability will be assumed – Vulnerability: Safeguarding/DoLS Considerations? If yes, what?
Hospital Consultant: Allergies: Prognosis Day/s Week/s Month/s Year/s Primary diagnosis (main reason for referral) Other significant conditions’ Referral Reason for the referral: Symptom control Psychological Support Terminal care Staff Carer Requested service(s) Please refer to our website for the list of groups currently offered by the services listed under ‘Other’. These groups are held in Pemberton Place Inpatient Unit Specialist Community & Crisis Support (SCCS) Hospice at Home (Not applicable to Nursing Home Residents) OrangeLine Other (Please state) Physiotherapy /Occupational Therapy /Pastoral Care/Complementary Therapy /Family Support Services/Bereavement/ Heart Failure Clinic Has an EOL care plan been created in Health Analytics? Current problems requiring specialist palliative care and input: Resuscitation status: Advanced care plan: Vulnerabilities/Specific Needs – If none listed, no vulnerability will be assumed Vulnerability: Safeguarding/DoLS Considerations? If yes, what?
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