District Nurse / Community Nurse / Integrated Community Care Team

Referral

Please note any within 24 hours requests requiring a visit on the same day or urgent 0-2 referrals cannot be processed electronically - to make an urgent referral please contact Single Point of Contact - 0300 304 5555

Diagnostics - please select *

Blood Pressure ECG

Blood Test Specimen

To note - District Nurses do not undertake diagnostic Dopplers

Blood Pressure

Does the patient require a BP? *

Reason (e.g. medication review) *

Is this in relation to a Long Term Condition? *

Blood Test

Reason blood test required

Blood test requested *

Routine Repeat

Urgent

Date required

Is this blood test related to a long term condition review? *

Yes

Request processed via ICE? *

Yes

If yes, which blood test(s)

Is a fasting blood test required? *

Yes

Where are the blood forms? *

ECG - (Non-Urgent only)

Reason for ECG *

Is this in relation to a Long Term Condition? *

Specimen Collection

Specimen collection requested: routine, urgent or repeat required *

routine repeat

urgent

Type of specimin required *

Date required *

Request processed via ICE? *

Is this in relation to a Long Term Condition? *

WOUNDCARE: Surgical

Date of wound onset *

Location of wound *

Cause of wound (if known)

Size of wound *

Current treatment *

Any sutures to be removed? *

Are the required dressing with the patient? *

WOUNDCARE: Traumatic

Date of wound onset *

Location of wound *

Cause of wound (if known)

Size of wound *

Current treatment *

Any sutures to be removed? *

Are the required dressing with the patient? *

WOUNDCARE: Lower Leg

Date of wound onset *

Location of wound *

Cause of wound (if known)

Size of wound *

Current treatment *

WOUNDCARE: Pressure Ulcer Management

Does the patient have a wound? *

Yes

Location of wound *

Size of wound *

Duration of wound *

Current treatment *

Cause of ulcer (if known)

Has the Pressure Ulcer been datix'd? *

Is pressure relieving equipment in situ *

Yes

Reason for referral for Pressure Ulcer prevention assessment *

WOUNDCARE: Leg Ulcer

Does the patient have a history of leg ulceration? *

Date of wound onset *

Location of wound *

Cause of wound (if known)

Size of wound *

Current treatment *

Has a doppler been performed? Date and result of doppler *

Is the patient under vascular clinic? *

WOUNDCARE: Wound Drain

Type of drainage system *

Duration drain inset *

2 Weeks consumables supplied *

Yes

Expected removal date or volume *

WOUNDCARE: Chest Drain

Type of drainage system *

Date inserted *

Reason for insertion *

Date of review by discharging consultant *

WOUNDCARE: Vac Therapy

Please note, if you are referring for VAC therapy, please also refer to Tissue Viability service

Type of therapy inset *

Machine number and who does the machine belong to *

Dressing type *

Foam type *

Pressure of therapy *

Date commenced *

CATHETER CARE: Intermittent

To note, if the patient is experiencing pain, the catheter is blocked or bypassing, please call to make an urgent referral please contact Single Point of Contact - 0300 304 5555

Does the patient have the dexterity and capacity to self-care? *

Has the patient support from a carer to provide daily catheter care? *

Yes

Name of carer/care agency *

Carers contact telephone number *

Reason for referral *

Reason for procedure *

Urine retention Urethral dilatation Other, please specify

Stricture therapy Clean intermittent catheterisation

Other, please specify *

Please give more detail *

Plan of care *

Please specify the frequency of intermittent catheterisation *

Please provide details of the patient's long term treatment plan *

Please provide details of any follow up care to be provided by acute services *

Catheter prescription details *

On discharge has the patient been provided with a two week supply of intermittent catheters? *

Yes

Please specify the type of intermittent catheter to be used *

Manufacturer *

Catheter size *

Please provide details of the patients preferred Dispensing Appliance Company or Local Pharmacy *

Please provide the details of the patient's consultant and other relevant acute service clinicians inlcuding; Consultant / Key worker name: Hospital Contact telephone number *

CATHETER CARE: Indwelling

Does the patient have the dexterity and capacity to self-care? *

Reason for referral *

If weekly bag changes are required, have they been assessed for self care? Is a care package or family support already in place for this? *

If the patient requires support from a carer to self manage or provide daily catheter care, has this been arranged? *

Yes

If this is required this needs to be sorted before you refer to CNN

Name of carer/care agency *

Carers contact telephone number *

Details of care required *

Reason for catheterisation *

Management of Incontinence Urine retention Palliative/End of Life reduced mobility Other

Tissue viability Post surgery care Outflow obstruction

Other - please specify *

Please specify type of catheterisation *

Urethral indwelling catheter

Supra pubic urinary catheter

Please give more information *

Date catheter inserted *

Date catheter last changed?

Date next catheter change due *

How often does catheter require changing? *

Please provide details of the patient's long term treatment plan *

Please provide details of any follow up care to be provided by acute services *

Please specify the type of indwelling catheter to be used *

Manufacturer *

Catheter size *

Please specify drainage equipment used *

Leg bag

Night Drainage Bag

Leg Bag - Manufacturer *

Leg Bag - Type and Size *

Night Drainage Bag - Manufacturer *

Night Drainage Bag - Type and Size *

Fixation device manufacturer *

Fixation device type & size *

Catheter Bag Stand - Catheter manufacturer *

Catheter Bag Stand - Catheter type & size *

Is the patient currently managed with a flipflo valve or similar device? *

Yes

Device details, Manufacturer, Type and Size *

Please provide details of the patients preferred Dispensing Appliance Company or Local Pharmacy *

On Discharge - Has the patient been provided with a hand held catheter Passport *

On Discharge - Has the patient/carer been provided with verbal and written advice regarding Long term Indwelling Catheter management & Care *

Has the patient been supplied with the following equipment as part of their discharge prescription

Spare indwelling catheter 2 weeks supply of night drainage bags Catheter stand

2 weeks supply of catheter Leg bags Catheter fixation device 2 weeks supply of catheter valve device

Please provide the details of the patient's consultant and other relevant acute service clinicians inlcuding; Consultant / Key worker name: Hospital Contact telephone number *

Bowel Care

Please note - we do not undertake phosphate enemas

Type of Enema, Suppository *

Reason for Enema, Suppository *

Has rectal examination been undertaken? *

Yes

If yes, who performed the examination *

If yes, what were the findings *

Has the enema been prescribed? *

Has oral medication prescribed? *

Yes

If yes, type and frequency *

Is the enema with the patient? (If the enema is not with the patient, District Nurses will be unable to visit) *

PEC Tube

Frequency of flush *

Bowel irrigation system, frequency *

Is the PEC being flushed and vented *

Yes

If yes, frequency of flush *

Consultant details (this is the consultant who requested the PEC to be inserted) *

Transanal Irrigation (option for Specialists only)

Please specify *

Frequency of irrigation *

Amount of irrigation fluid *

Medication Administration

Criteria for Accepting Patients for medicines administration within the CNN's.

The following Criteria must be met:

The patient is housebound. Patients who are not housebound should be referred back to their prescriber to allow alternative arrangements to be made.
The patient is unable to self-administer their medication or is unable to use an aid to support self-administration.
Previous training to self-administer has been tried but has been unsuccessful or the patient is deemed unsuitable to self-administer.
The patient has no relatives or carers to administer the medication.
The community nurse administering is competent to administer the medication.
The medicine is classified as green or amber according to the SWYAPC or is on the accepted Red list (see guidance)
The route/method administration below has been considered.

Route of Administration	Acceptance onto caseload
Oral	No. Not undertaken by CNN’s. Care agency to support as necessary.
Intravenous	Not undertaken by CNN’s except for line maintenance.
Topical	Not routinely emollients or medicated creams. Care agency to support as necessary. Medicated creams and emollients will be applied if under a bandage or dressing that is being administered by the CNN. The administration of patched can be accepted onto caseload provided that the care company will not administer.
Rectal	Yes
Vaginal	Yes
Via feeding tube e.g., NG, PEG	Not in North Kirklees – Fresenius provide training to care companies to North Kirklees to enable them to administer. In Greater Huddersfield patients will only be accepted to avoid delays in discharge.
Eye/Ear/Nose drops	Yes. Consider whether the patient would be able to administer using an aid and supply as appropriate.
Intramuscular	CNN’s can administer medicines via intramuscular injection. Locala do not accept referrals for vaccination of housebound patients.
Subcutaneous	CNN’s can administer medicines via sub-cutaneous injection.

Please note, District Nurses do not administer oral medications

Reason for referral *

Injection Patches

Eye drop Topical

Type of medication *

Frequency *

Route *

Dose *

Location of prescription *

Acute trusts please attach copy of medication administration sheet / discharge letter Upload file

Start date *

Stop date

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

Yes

We are not able to administer if this is not in place

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? *

When is the next clinical review date (it is assumed administration can continue up to review date, unless otherwise advised) *

Attach clinic letter Upload file

Diabetes

Please note - if you are submitting a referral for insulin, please contact SPOC so that it can be discussed with a SPOC clinician to prevent any delays to treatment on 0300 304 5555

Does the patient (or family member) have potential to self administer? *

Yes

If yes, DN team will visit for a fixed period determined on a first consultation to support safe self-administration. Patient will be discharged from the service once safely administrating.

Date of first visit *

Time of visit required *

Hour

Minute

Prescription evidence on system including type of Insulin *

Yes

Please attach copy of prescription/discharge letter Upload file

Strength of Insulin *

Dose of Insulin *

Frequency of Insulin *

Administration device type *

Does the patient have a blood glucose monitor? *

Review date *

Palliative Care

Diagnosis (including patients understanding) *

Prognosis *

Carer involved *

Support services available at home *

Hospice involvement *

Treatment required *

Information entered on EPACSS *

Yes

Is Patient fast track? *

Yes

Has a RESPECT form been completed and sent home with the patient? *

Has the patient been discharged with anticipatory medication? *

Yes

If yes, does the patient have a syringe driver? *

Yes

If yes, please provide details: what time does it need changing/type of Syringe driver (12/24 hour) *

Please attach prescription Upload file

What equipment is in place to support patient? *

Will they have a care package at home? *

Frequency of care package *

Sitters required *

DNAR Form completed *

Yes

Out of hours hand over form completed *

Enteral Feed

Reason for placement *

Type of tube in situ *

Tube size (Fr) *

Location of tube tip *

Placement hospital *

Date of insertion *

Plans for replacement *

Spare tube provided *

Frequency of tube change/maintenance *

Please attach copy of Feed Regime/Medications Upload file

Feed Regime

Type *

Volume/ Infusion time / rate *

Amount and type of flush required *

Patient registered with Nutricia *

Patient registered with Fresinus *

Is enteral feed nurse involved with patient? *

Medication to be administered through tube *

Please attach copy of Feed Regime Upload file

Maintain Entral Feeding tube

Reason for placement *

Type of tube in situ *

Tube size (Fr) *

Frequency of tube change/maintenance *

Balloon size *

Date of insertion *

Has all equipment been provided including PH testing strips? *

Yes

If no, we are unable to take onto caseload until all equipment has been provided *

Tracheostomy

Reason for Tracheostomy *

Is patients airway Patent (Upper Airway)? *

Yes

Product Information – Size *

Product Information – Type *

Product Information – Brand *

Fenastrated? *

Yes

Cuffed? *

Yes

Daily Care *

Is patient independent with care needs? *

Yes

Is Emergency Equipment provided *

Yes

Frequency of Change *

Date of Last Change *

Chemotherapy disconnection and CVAD maintenance

Reason for referral *

Chemotherapy disconnection Both

CVAD Maintenance

Type of CVAD *

CVAD

Date inserted *

Date maintenance required *

Please provide maintence regime e.g. Sodium Chloride/Heparin *

Chemo Disconnect

Time disconnection required *

Does patient have spillage kit? *

Yes

Please confirm patient has contact details for issues/problems with line *

Yes

Anything else/additional information that may support this referral?