MERCY PALLIATIVE CARE
Ph   03 9313 5700   Fax  03 9364 9198		

Facsimile
To: 	Intake Coordinator, Mercy Palliative Care 	From: 		
Fax No:	9364 9198	Reply Fax:		
Cc:		Reply Ph:		
Date:	<<Miscellaneous:Date (short)>>	
Re: 	Request for Mercy Palliative Care Review	
	o Urgent	o Routine	o Please Comment	o Please Reply
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Home Address or Residential Care Facility
Facility Name:*if applicable	<<RACF Name>>	
Address:	<<RACF Address>>	
Phone number:	<<RACF Phone Number>>	
Contact Person:	<<RACF Contact Person>>	

Patient details
Surname:	<<Patient Demographics:Surname>>	DOB:		
Given Name:	<<Patient Demographics:First Name>>	Mercy Health UR No:
(if known)	<<Mercy Health UR No>>	
Medicare No:	<<Patient Demographics:Medicare Number>>	Country of Birth:	<<Patient Demographics:Country of Birth>>	
GP:	<<Doctor:Name>>	Preferred Language:	<<Patient Demographics:Language Preferred>>	
GP Ph No:	<<Doctor:Phone>>			

The following referral information is included:  * Denotes mandatory referral information
o Registration details (also include NOK/medical treatment decision marker / advanced care directive)*
o Mercy Palliative Care ISBAR Referral *
o Recent medical/hospital correspondence*
o X-Rays / CT / MRI / PET / Pathology reports (if applicable)
o Hospital discharge summary (if applicable)
Please sign below to confirm you are aware that incomplete referrals could delay the review process

Signature …………………………………………………..	Name: …………………………………..

Mercy Palliative Care	

UR No:	<<UR No.>>
Surname:	<<Patient Demographics:Surname>>

Given Name:	<<Patient Demographics:First Name>>

DOB:	<<Patient Demographics:DOB>>

OR Attach Patient Label here	

ISBAR REFERRAL FOR PALLIATIVE CARE REVIEW
DATE: <<Miscellaneous:Date (short)>>	Phone: 1300 369 019  Fax: 9364 9198	
Identify

o Consent from patient for referral (if not, state reason): 

o GP Details: (if not already included): 

o Consent from GP for referral (if not, state reason): 

o Consent from family for referral (if not, state reason) : 	
Situation (Diagnoses / Reason for referral)

o Diagnoses: (if not state reason): 

Reason for referral: (please tick)

o Symptom management    o Support for anticipated deterioration   o End of Life Care	
Background (Relevant medical & social history)
Past medical history:
<<Clinical Details:History List>>

Medications:  (or attached copy of medication chart o  )
<<Clinical Details:Medication List>>

Allergies/Sensitivities:  
<<Clinical Details:Allergies/Adverse Reactions>>

Social history:
<<Clinical Details:Social History>>

Advanced care directive/ (please attach copy / details) 

Assessment (Actions taken / Relevant investigations / Impression of situation / risk identified)

Cognitive State:     o Alert   o Confused  o Agitated   o Drowsy

Functional status:    o Independent/supervision  o Chair bound   o Bed Bound

Nutrition:   o Full/Normal   o Deteriorating   o Nil       Route:   o Oral   o NG    o PEG    o Nil 

Clinical Symptoms:
o controlled with medication/s   
o requiring PRNs 
o not controlled with medication/s

Impression of situation/problem (include any actions taken):  

	
Request (Desired outcome of review)