Communication

What is the patients main spoken language? *

Is an interpreter needed? *

Yes

If yes, what language? *

Is 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? *

OPAT Service Questions

Responsible consultant and contact details *

Allergies/intolerances and reaction/sensitivity *

Infection risks: (MRSA, C-Diff, COVID) *

Past Medical History *

Resus status *

Yes for Resus

Not for Resus

Where is Resus paperwork stored? *

Is patient aware of Resus status? *

Yes

Summary of diagnosis, imaging and procedures: *

Social Issues/Other agencies involvement: (are they able to cope at home, mobility issues/changes) *

Weight

Height

Please provide baseline observations - BP, Heart Rate, Temperature, Sats, Resp. Rate *

Current NEWS score and Escalation Plan *

Please tick here to show you understand that submission of referral does not mean its been accepted to service. A member of the OPAT service will call to discuss. Do not discharge until the acceptance onto service has been confirmed.

Patient Details

Please note, the contact number for OPAT has now changed to 0300 304 5184

Patient name (including title) *

NHS number *

Date of birth *

Gender *

Address *

Location of patient for OPAT treatment, if different from address above

Patient telephone number (including mobile) Please indicate which is the preferred number for contact. *

Ethnicity

Overseas visitor? *

Yes

Are there any relevant safeguarding concerns or issues? *

Yes

If yes, please give details *

Are there any risks associated with visiting or providing support for this person? *

Yes

If yes, please give details *

Referrer details

Referrer name and occupation (i.e. consultant, nurse) *

Referrer telephone number (including bleep/extension) *

Referrer e-mail address *

Referred from (including hospital ward and ward contact details) *

Consent

Does the service user consent to the request for this service to be made? *

Yes

If no, has an MCA and best interest decision been made and documented in the service users notes? *

Yes

Please give further information *

Do they consent to share information *

Yes

GP Details

GP surgery *

Address *

Postcode *

Telephone number

Next of kin

Name of next of kin *

Next of kin relationship *

Next of kin address

Next of kin telephone *

Key holder - including keysafe code *

Next of kin e-mail

Has patient given consent for Next of Kin to be contacted *

Yes

OPAT Referral Form