COVID-19

Please note - a housebound patient is one who cannot leave their home at all, or without significant assistance which cannot be provided, either temporarily or permanently, due to severe physical or mental or illness or disability.

All mandatory sections needs to be completed with the relevant information to support triage (“n/a” will not be accepted). Your referral may be returned without sufficient information.

Has self-care been assessed?

Referrers from acute settings should provide this information to best of their ability. Not doing so can slow the process down considerably.

Date of referral

Time of referral

Hour

Minute

Estimated date of discharge

Date medically optimised for discharge

Date discharge ready

Reason for admission *

Reason for referral *

Hospital discharged from

COVID-19 status

Negative

Positive

Date of COVID-19 test

Patient Details

If contact details are incorrectly input where mandatory the referral cannot be processed

Name *

Address *

Telephone Number *

Patient has consented to information sharing? *

Yes

Patient has consented to referral? *

Yes

NHS Number *

Date of Birth *

Overseas visitor? *

Yes

Patient issued with any equipment e.g. mobility equipment, oxygen *

Yes

If yes, which equipment? *

Referrer Details

If contact details are incorrectly input where mandatory the referral cannot be processed

Referrer name *

Referrer email *

Contact Number *

If referring on behalf of a patient please enter generic contact details in case of further information or rejection notifications, to prevent delay in treatment.

Urgency

For Urgency 1: 1-4 hours, please call SPoC directly on 0300 304 5555.

Community

What is the patient's main spoken language? *

Is an interpreter needed? *

Yes

Are there any communication needs for this patient or their parent/carer? For example, related to learning disabilities or autism or due to impaired sight/ hearing or any other reason/s. *

Yes

What might be helpful when communicating with this patient or their parent/carer? *

Environment

Does the visit require two members of staff (e.g. to hoist the patient)? *

If yes, provide details of the risks: (dangerous dogs, environmental infestations, history of offenders residing at the property etc) *

Can the patient open their door? *

Yes

If no, what the keysafe number: *

Request Details - Wound Care

Wound Care Request Details

If other, please specify *

Location of wound: *

Please upload a photo of the wound Upload file

Request Details - Catheter Care

Catheter Care Request Details

Is the catheter blocked? *

Yes

Is the catheter bypassing? *

Yes

Does the patient have any catheter supplies? *

Yes

Request Details - Enemas

Enemas Request Details

Has the enema been prescribed? *

Yes

Is the enema in the patient house? *

Yes

Request Details - Ear Syringing

Ear Syringing Request Details

Reason for ear syringing request? *

Has the patient already been assessed by a GP for ear syringing? *

Yes

Has the patient been administering olive oil? *

Yes

For how long has the patient been administering olive oil? *

Request Details - Community Nursing Assessment

Community Nursing Assessment Request Details

Please give as much information as to why an assessment is needed? *

Has self-care been assessed? *

Yes

Request Details - Injections

Injections Request Details

Name and strength of injection:

Frequency of injections?

Dose of the injection?

Route of injection:

Has the prescription been sent and will the item be at the patient house?

Yes

Legal authorisation is required to administer medication.

A valid direction to administer is a prescription, that clearly identifies the patient and prescriber, and details the date of issue, the medicine name, strength, form, route/method of administration and dosing regimen (dose, time/frequency of administration, and duration of treatment if applicable) signed by the prescriber.

Alternatively, an entry visible to Locala in SystmOne that confirms such a prescription has been issued, a medication chart or hospital letter containing sufficient detail and authorised by an appropriate prescriber may meet the requirements.

If in doubt, please contact our clinicians via 0300 304 5555 for advice.

Where is the direction to administer/dispensed item?

Is this drug classified as a red drug?

Yes

IF RED DRUG - What is the stop Date? *

IF RED DRUG - When is the next clinical review date? *

It is assumed administration can continue up to review date, unless otherwise advised:

IF RED DRUG - Has a hospital administration chart been provided? *

Yes

IF RED DRUG - Special Monitoring required as part of administration? *

IF RED DRUG - Attach clinic letter: * Upload file

Other

Other Request(s) Details

Please explain your other needs here *

District Nurse / Community Nurse / Integrated Community Care Team