REQUEST FOR COMMUNITY NURSING SERVICES
Refer via Information & Access Service
FAX ONLY: 03 4215 7795 
							
GP Referral
		Referral Date: Miscellaneous.Date
Feedback Requested:  Feedback requested

Referral to:
Barwon Health Community Nursing

Phone: 
Information & Access- 03 4215 7700

Note

Referral Urgency: Referral Urgency
Referral valid for: Referral valid for		Referring General Practitioner:
Name:Treating Doctor.Name
Practice: Practice.Name
Address:Practice.Address
Phone:  Practice.Phone
Fax:  Practice.Fax
Email: Treating Doctor.E-mail
Provider No.: Treating Doctor.Provider Number	

Patient/Client/Consumer details:
Title: Patient Demographics.Title
First name: Patient Demographics.First Name
Surname: Patient Demographics.Surname
Preferred Name: Patient Demographics.Popular Name

Date of Birth: Patient Demographics.DOB          Age: Patient Demographics.Age
Gender: Patient Demographics.Gender 

ATSI: Patient Demographics.ATSI Status
Interpreter required: Interpreter
Preferred language is: Preferred language
Please consider Telehealth for this patient: Telehealth 
Cultural safety requirements: Cultural Safety
Access/Support requirements: Access/Support		Address: Patient Demographics.Full Address
Mobile: Patient Demographics.Phone (Mobile)
Email: Patient Demographics.E-mail
Home Phone: Patient Demographics.Phone (Home)
Work Phone: Patient Demographics.Phone (Work)
Preferred method of communication: Preferred contact 

Medicare: Patient Demographics.Medicare Number  Expiry: Patient Demographics.Medicare Expiry Date
Pension/HCC: Patient Demographics.Pension Number
DVA: Patient Demographics.DVA Number
Insurance: Patient Demographics.Health Fund NamePatient Demographics.Health Fund Member Number

NOK/Carer/Alternate contact:
Name: Patient Demographics.NOK Name  
Phone: Patient Demographics.NOK Mobile Phone
Relationship: Patient Demographics.NOK Relationship

Consent to referral: Consent to referral
Consent to share information: Consent- information
Is this a 2nd referral for the same problem: 2nd referral?
Usual GP (if not referrer):  Usual GP	

WestVic HealthPathways provides guidance in patient assessment, management and referral. 
HealthPathways	

Reason for referral:
Service requested

Additional info

Past Medical History:
Clinical Details.Past History

Social History:
Clinical Details.Social History

Family History:
Clinical Details.Family History

Current Medications:
Clinical Details.Medication List

Alerts:
Clinical Details.Warnings

Alcohol History:
Clinical Details.Alcohol

Smoking Status:
Clinical Details.Smoking
If smoker, smoking cessation discussed: Smoking cessation

Investigations/Results:
Clinical Details.Result List (Selected)

Electronically signed by: Treating Doctor.Name

Clinical Information: Patient Demographics.Full Name DOB: Patient Demographics.DOB

Allergies/Adverse drug reactions:

Clinical Details.Allergies

Medication Authority to administer Medicines:
(This section is to record only medications to be dispensed/administered by nurse)
(Legible handwriting or typed orders please)

DATE	MEDICATION	DOSE	FREQ	ROUTE	INDICATION	DATE TO BE CEASED	
Miscellaneous.Date							
Miscellaneous.Date							
Miscellaneous.Date							

Routine Insulin Orders:

DATE	 INSULIN	UNITS	FREQ	TIME	ROUTE	DATE TO BE CEASED	
Miscellaneous.Date					SUBCUT		
Miscellaneous.Date					SUBCUT		
Miscellaneous.Date					SUBCUT		
Miscellaneous.Date					SUBCUT		
Miscellaneous.Date					SUBCUT		

Correction doses:

DATE	PRE-MEAL BLOOD GLUCOSE	INSULIN	ADDITIONAL DOSE	ROUTE	DATE TO BE CEASED	
Miscellaneous.Date				SUBCUT		
Miscellaneous.Date				SUBCUT		
Miscellaneous.Date	> 20 mmol/L			SUBCUT		

Contact: Treating Doctor.Name

Doctor's Signature: _____________________________________
 (Please sign here for above orders to be given by nursing staff)

Treating Doctor.Name
Date: Miscellaneous.Date

Clinical Information: Patient Demographics.Full Name DOB: Patient Demographics.DOB

Reportable levels: (Reference User Guide to Insulin - National Safety Quality Council)

Suggested reportable levels 

I agree with the suggested reportable levels   Yes    No ›  (If no, delete or adjust the following as required)

Clients to use their own meters
Blood glucose <   4 mmol/L        	
Blood glucose > 20 mmol/L
Two consecutive BGL > 16 mmol/L
Three consecutive BGL > 12 mmol/L
If BGL > 15 in T1DM and ketones > 0.6
If unwell T1DM and ketones > 0.6
If BGL > 20 in T2DM and ketones > 0.6

Syringe Driver or Infusion Device:

DATE	MEDICATION	DOSE	FREQ	ROUTE	DATE TO BE CEASED	
Miscellaneous.Date						
Miscellaneous.Date						
Miscellaneous.Date						

Doctor's Signature: _____________________________________ 
(Please sign here for above orders to be given by nursing staff)
Treating Doctor.Name
Date: Miscellaneous.Date