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E-Referral
Main Application
Date of Referral:
Bed:
Source of Referral:
Unit:
Date of Admission:
Ward Tel:
Patient’s Ward:
Ward Fax:
Expected Date of Discharge:
Biodata
i) Patient’s Particulars
Case No.:
Race:
Name:
Gender:
NRIC/Passport/FIN/UIN/No.:
Citizenship/
IC Colour:
Date of Birth:
Marital Status:
Age:
Religion:
Telephone:
Address:
Language(s) Spoken:
Dialect(s) Spoken:
ii) Contact Person
Name:
Home Phone:
Relationship of Applicant:
Hand Phone:
Language(s) Spoken:
Office Phone:
Application To Hospice Palliative Care Service
1.
Assign to Hospice (Service Type):
Hospice Name (Service Provider):
2.
Reason(s) for Referral:
3.
Referring Consultant/Registrar/GP:
4.
Hospital/Dept/Clinic:
5.
Other Consultants involved:
6.
Is Hospital Palliative Care team involved?:
7.
Is patient currently under a hospice service?:
8.
Has Patient/Family been informed of referral?:
9.
The following have been informed of diagnosis:
10.
The following have been informed of prognosis:
Medical Report
Name of Patient:
NRIC:
Primary Diagnosis:
Histopathological Diagnosis:
Site of Metastases:
Date of Diagnosis:
Prognosis:
Present Condition:
Summary of Medical History
a) Brief of history of cancer/terminal illness, including presentation, treatment and progress
b) Current Issues
c) Relevant Investigation & Examinations
d) Co-morbidities:
e) Does patient have any history of drug allergy?:
Current Medication
No.
Name of Drug/Dose/Frequency
Reason Prescribed
1.
2.
3.
4.
5.
Other Remarks
Mental Status:
Feeding:
Mobility:
Patient requires the following special care:
Respiratory:
Nutritional & Gastro-Intestinal:
Urinary Tract:
Others:
Doctor completing this report:
Name:
Designation:
Hospital/Department/Clinic:
Telephone:
Fax:
Date:
Admission
Details and Instructions for Admission Into In_Patient Hospice
Date of Admission:
Name of Patient:
NRIC:
Scheduled Admission Date:
Scheduled Admission Time:
Ward/Bed/Unit Inpatient Hospice:
The following medical official documents must accompany the patient at admission
Doctor’s discharge summary/memo:
All relevant x-rays/chest x-rays:
All relevant laboratory investigation reports:
MSW/reports if available:
Supply of medication:
Original NRIC, PA/MFEC card (and/or CSC card applicable):
Others Instructions/Remarks
For any enquiries or notification or changes, kindly contact the following officer in charge:
Name:
Designation:
Email:
Telephone:
Date:
Fax:
Confirmation Code:
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