Sydney District Nursing Referral

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Sydney District Nursing Referral Form

Sydney District Nursing Referral Form

* Required Fields. Please submit your application by clicking the 'SUBMIT' button.

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Referrer Details

First name *

Last Name *

Email *

Contact Number *

Referring Service

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MAC ID

Is the patient eligible for a MAC ID?

Yes No

For more information on My Aged Care eligibility see https://www.myagedcare.gov.au/am-i-eligible

MAC ID *

Nursing referral Code

Are they on a Home Care Package?

Yes No

Package Level:
Provider Details:

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Patient Details

Patient's First Name *

Patient's Last Name *

Patient's Date of Birth *

Current Address *

Private address
Residential Aged Care Facility
Other

Other please specify

Address *

Postcode *

Telephone(preferred no.)*

MRN

Gender *

Male
Female
Indeterminate/Intersex
Not specified

Does the patient identify as LGBTIQ+?

Yes
No
Unknown

Title

Financial Status *

Medicare Eligible
DVA
Work Cover
Medicare Ineligible

Aboriginal and/or Torres Strait Islander *

No
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander

Interpreter Required? *

Yes
No

Language(s) :Specify language spoken

Consent *

Patient consent for referral
GP aware of referral
Person to contact/Carer aware of referral

Is the patient suitable for clinic? (Excluding palliative care patients) *

Yes
No

Provide Details

Best PERSON TO CONTACT (specify 'as above' if the same)
Access Care Team may need a contact for further information. Please provide details of the appropriate person.

First Name*

Last Name*

Relationship*

Address(person to contact)*

Postcode

Telephone*

Current GP

First Name*

Last Name*

Provider No.

Phone*

Fax

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Risk Alert

Are there any safety, security or clinical risks? *

Yes
No
Unknown

Further details *

Domestic Violence Animals of concern at home Weapons
Alcohol and Substance Abuse Squalor Suicide Risk
Mental Health Issues Behaviour Issues Property access issues
Environmental Risks for staff Falls Risk Other

Please provide details *

Other Risk Factors *

Known Multi-resistant Organism
Infectious Diseases
Not Applicable

Specify

Hazardous Drugs *

Cytotoxic, non-cytotoxic, reproductively hazardous
No

Specify

Allergies *

Yes
No

Provide further details for Allergies *

Bariatric (Bariatric refers to a person over 120kg) :

Is the patient classified as Bariatric? *

Yes No

Patient Weight

Recent OT assessment and home assessment

Current equipment at home

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Social History

Social circumstances including level of family support, home situation, living situation and any concerns or issues *

Guardianship/Advocate :

Is there currently an appointed Guardian?

Yes No
Details:

Is there currently an appointed Advocate?

Yes No
Details:

Does the client have an Advance Care Directive?

Yes No
Attached

Other Services

NDIS DVA
Other
Other:

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Relevant Medical History

Primary Diagnosis *

Past Medical History *

Requested date for commencement of care/assessment *

Medical Governance (Medical Officer responsible for care of patient/clinical escalation/managing treatment orders) *

Medical Officer (MO) Name

MO contact number

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Reason for Referral

Reason for Referral *

Wound Care
Urinary Catheter Management
Palliative Care
Bereavement Visits
Intravenous(IV) medication (PIVC, Midline, CVAD)
Drain Management
Negative Pressure Wound Therapy (VAC Dx)
Compression Therapy

Urinary Catheter Management

Reason for Urinary Catheter Management *

Suprapubic Catheter(SPC)
Indwelling catheter IDC
Authority to Perform Clinical Procedure by Nurse form provided

Is a trial of void required?

Yes
Please also refer to ACC&R Continence CNC
No

Known issues in catheter change?

Yes Please consider referring to Continence CNC No

Known risk of Autonomic Dysreflexia (AD)? *

Yes No

Order for treatment of AD provided on CH medication chart? *
(e.g. Glyceryl Trinitrate (GTN) spray or Anginine tablet) (Sydney District Nursing Medication Chart)

Yes No

Please provide details of treatment plan (e.g. any planned surgery/catheter removal, duration of care required…)

Wound Care

Wound Description*

Lower Leg Ulcer Pressure Injury Stage
Diabetic /neuropathic foot ulcer Acute surgical
Chronic Wound ( More than 4 weeks) Laceration
Skin Tear
Other
Other Details :

Wound Location

Approximate date of onset *

Compression therapy

Graduated Compression therapy

* Authority for Graduated Compression Therapy provided
Please note current Arterial Brachial Pressure Index (ABPI) or Toe Brachial Pressure Index (TBPI) assessment results required if Authority for Graduated Compression Therapy form is not being completed by a Vascular Specialist.

NWPT dressing

Negative Wound Pressure Therapy (NWPT) Dressing

* Negative Pressure Wound Therapy Pathway SYDLHD form provided

Details of Treatment plan (e.g. suggested dressing frequency, dressing products, medical review)

Drain Management

Drain Type *

Drainage requirements

Suction requirements

Dressing Frequency

Removal Instructions

Sutures in place

Yes No

Sutures to be removed

Yes No

Authority to Perform Clinical Procedure by Nurse form provided

Negative Pressure Wound Therapy ( VAC Dx)

Please complete the Negative Pressure Wound Therapy LOA form and attach the completed form to the referral

Negative Pressure Wound Therapy

Compression Therapy

Please complete the Authority for graduated Compression Therapy form and attach the completed form to the referral

Authority for Graduated Compression Therapy

Bereavement Visits

Name of deceased patient *

Relationship to the deceased *

Palliative Care

What Palliative Care service does the patient require?

Palliative care nursing Patient is imminently dying Chronic Disease Palliative Care

Referring for

Social Work
Occupational Therapy
Physiotherapy
Clinical Psychologist
Dietetics
Speech Pathology
Senior Aboriginal Health Worker - Palliative Community Care

Reason for Referral to Social Work

Social work is a holistic service that provides psychosocial assessments and supportive interventions for patients, carers and families. This includes linkages with appropriate services such as NDIS/My Aged Care. Social work can provide intervention and support around adjustment to illness, future planning, legal/financial & accommodation issues for patients. A referral to Social Work is required if there is family/domestic violence or child wellbeing/protection concerns.

Reason for Referral:
(you may select multiple)

Psychosocial Assessment
Future Care Planning & Education
Vulnerable Patient/Carer
Counselling (Adjustment to Illness/Grief & Loss/Children at home)
Carer Stress
Services at home
NDIS
Planning for Aged Care Facility
Financial/Accommodation Issue
Legal (Wills, POA, Guardianship)
Domestic/Family Violence/Elder Abuse
Child Protection/Wellbeing Concerns

Please provide background to the reasons for referral where possible:*

Reason for Referral to Occupational Therapy

Occupational therapy is a holistic service that provides functional assessments and intervention to maximise a person's level of independence and their quality of life. It addresses the physical, cognitive, psychosocial and environment factors that may impact or limit their function.

Reason for Referral:
(you may select multiple)

EOLC set up
Pressure injury present/risk
Home access and safety
Equipment prescription
Sudden change in functional
Manual handling injury risk
Functional transfer assessment
Energy conservation and fatigue management
Lymphoedema management
Cognitive/perceptual impairment
Upper limb assessment
Other
if Other, Details

Other relevant *

Reason for Referral to Physiotherapy

Physiotherapy provides mobility assessment and intervention, exercise prescription, symptom management and manual handling risk/carer training. Referrals accepted for patients with:

Any AKPS score for mobility/transfer assessment
AKPS score less than or equal to 50 for other reasons of referral

Reason for Referral:
(you may select multiple)

Mobility Assessment
Strength / Conditioning
Falls prevention / balance training
Sudden change and/or rapid decline in functional status
Respiratory / breathlessness management
Carer training / manual handling injury risk
Oedema management (exercise based)
Pain management
Fatigue management

Other relevant Info *

Reason for Referral to Clinical Psychologist

Clinical psychology offers evidence-based, client-centred psychological support to improve the mental health and wellbeing of clients, families, and carers. This includes assessment of psychosocial needs, integrative treatment for symptom relief and quality of life promotion, and carer support.

Reason for Referral:
(you may select multiple)

Psychiatric assessment / treatment (e.g. distress, emotional dysregulation, trauma)
Adjustment issues (e.g. health and illness, loss)
Relational concerns (e.g. family, partner, friends, abuse)
Pain and sleep management
Carer stress (incl. complications of bereavement)
Other (Please provide details below)

Other Info

Reason for Referral to Dietetics

Dietetics is a holistic service that can provide dietary support to patients, families and carers in a way that is person-centred and promotes quality of life. This can include assistance with eating and drinking, or with enteral tube feeding. Dietetics can also assist with managing symptoms and educating families and carers on appropriate dietary strategies.

Please indicate the main reason/s for referral :
(you may select multiple) *

Unintentional weight loss

If known, please provide more information
(e.g. most recent height and weight, amount of weight loss, time period weight loss has occurred over):

Poor appetite or eating less than usual
Requires support to optimise eating and drinking
(this can include support for pressure injuries or requests for oral nutrition supplements)

Please provide any relevant information:

Symptom management (e.g. nausea or dry mouth)

Please specify the main symptoms impacting eating and drinking:

Requires support for enteral feeding (i.e. via a feeding tube)
Provide education and support to families and/or carers

Please provide more information
(e.g. family experiencing distress regarding change in client's appetite):

Other (e.g. client requesting information about alternative diets)

Please provide more information:

Please include other relevant information (e.g. current nutrition supplements):

Reason for Referral to Speech Pathology

Speech Pathology can provide assessment and support for patients with swallowing and/or communication difficulties to help maintain quality of life.

We also provide support to patients and carers/families to enhance communication skills to enable patients to maintain their autonomy participating in end-of-life discussions and to enhance social connectedness with family/friends.

Please indicate the main reason/s for referral
(you may select multiple): *

Communication - Communication Ax and intervention/strategies
Support with speaking, understanding, reading, writing
Unclear speech
Voice (e.g., soft, hoarse, running out of air when speaking)
Cognitive-communication support
Communication aids/supports (AAC)
Support for Advance Care Planning or EOL conversations

Swallowing
Signs of aspiration when eating/drinking (coughing/choking/SOB/voice changes)
Fatigue/SOB impacting swallow (e.g., reduced intake, prolonged mealtimes, difficulty chewing, distress)
Education/support to patient and/or family regarding swallowing strategies/diet modification/comfort feeding/oral intake at EOL
Tablet dysphagia
Saliva management and/or oral health
Other

Please include other relevant information:

Reason for Referral to Senior Aboriginal Health Worker - Palliative Community Care

The Senior Aboriginal Health Worker – Palliative Community Care provides holistic cultural support to Aboriginal and Torres Strait Islander patients, their families and carers. Our goal is ensuring respectful, culturally safe palliative and end of life care for Aboriginal and Torres Strait Islander patients within their communities.

Reason for Referral:
(you may select multiple)

Advance Care Planning / POA, Guardianship, Wills
Housing/ Accommodation /Financial
Home Care and Support Services
Discharge Planning/ Facilitating Transition of Care to Community
Cultural Support
Family Support /Conferences
Sorry Business and Bereavement
Concern for Wellbeing / Elder Abuse

Other Info

Palliative Care PHASE

Stable Unstable
Deteriorating Terminal
Unknown

RUG-ADL (Resource Utilisation Group-Activities of Daily Living) Tool

Bed Mobility

Independent Limited Physical Assistance
Other than two person physical assist Two or more person physical assist

Toileting

Independent Limited Physical Assistance
Other than two person physical assist Two or more person physical assist

Transfer

Independent Limited Physical Assistance
Other than two person physical assist Two or more person physical assist

Eating

Independent or supervision only Limited Assistance
Extensive assist/total dependence/tube feed

Palliative Care Problem Severity Score (PCPSS)

score - problem absent, mild, moderate and severe

Pain

0 1 2 3

Other Symptoms

0 1 2 3

Psychological/Spiritual

0 1 2 3

Family/Carer

0 1 2 3

Australian Karnofski Performance Scale (AKPS) (if known) score

Patient care plan

Preferred place for end of life care

Home Palliative Care Unit
Hospital Unknown RACF

Does the patient have an advanced care plan?

Yes No

Does the patient have any skin concerns such as pressure areas?

Yes No

Is the patient currently on active treatment?

Yes No

Are they on a Home Care Package?

Yes No

Are there end of life medications supplied?

Yes No

Please list end of life medications supplied

Medication chart in the home *

Yes No
Has been requested Not required

Requires subcutaneous medication administration via Syringe Driver/infusor?

Yes
No

Medication order provided on medication chart*
(Sydney District Nursing Medication Chart)

Currently inserted subcutaneous cannula (e.g. Saf-T-Intima) for medication administration?

Yes No

Date inserted

IV Medication

Has a current medication order been provided?

Yes, on the Medication Administration Record (MAR – eMEDs)
Yes, on the Community Health Medication Chart (Sydney District Nursing Medication Chart)
Yes on the paediatric NIMC
No

Has an order for Intra Muscular (IM) Adrenaline been provided on the “PRN” section of a Medication chart? *

Yes
No
Medication Standing order (SLHD HITH and RPAV Patients only)

Any plans for blood tests/therapeutic drug monitoring?

Please select (PIVC) OR (CVAD) *

Peripheral Intravenous Catheter (PIVC / DIVA)
Midline Catheter
Central Venous Access Device (CVAD)

Treatment details *

Peripheral Intravenous Catheter (PIVC)

PIVC inserted *

Yes Awaiting Insertion

Is the PIVC a DIVA(Difficult Intravenous Access) Cannula? *

Yes
No

PIVC insertion information/condition accessible to SDN on eMR? *

Yes
No (Please note: Insertion record & condition of PIVC must be available within the eMR prior to the commencement of SDN care.)

Insertion date *

Current PIVC insertion site VIP score *

Or Describe

Known PIVC insertion or management issues (e.g. problematic cannulations, extended dwelling time required)? *

Yes No

Special consideration for re-insertion (e.g. renal/oncology patient, preserve arm etc)

Midline Catheter

Midline inserted *

Yes Awaiting Insertion

Midline inserted by*

Insertion date *

Midline insertion record and current condition accessible to SDN within eMR? *

Yes
No (Please note: Insertion record & condition of midline must be available within the patients eMR prior to the commencement of SDN care.)

Current insertion site VIP score

Or Describe

Current external measurment length (cm) *

Dressing/valve change due on *

Known insertion or management issues
(e.g. allergies, sensitivities, dedicated lumens, ect)?

Yes No

Central Venous Access Device(CVAD)

(CVAD) *

PICC TVAD (Tunnelled Device)
Venous PORT Other

SDN Intravenous Access Devices Referral Checklist attached? *

Yes
No / Awaiting Insertion (Please note: Checklist must be completed and received by SDN prior to commencement of SDN care.)

Insertion date *

Radiological or ECG confirmation of tip location on eMR *

Yes No
Report faxed

Date attended *

Was the catheter repositioned after initial insertion? *

Yes No

Dressing/valve change due on *

Known management issues/specific requests. (e.g. allergies & sensitivities, dedicated lumen)

Yes No

Plans for removal of device(Venous ports referred for maintinance only) *

Yes No N/A

If referral is external to Sydney Local Health District, a discharge summary must be uploaded *

Yes
Not Applicable

Please attach any documents relevant to your referral (Max 3 documents)
Attach file as a PDF.
Documents include Discharge Summary, OT Assessment, Home Assessment, Palliative Care Plan, Authority to Perform Clinical Procedure by Nurse form, Authority for Graduated Compression Therapy form, Negative Pressure Wound Therapy Pathway SYDLHD form.

Upload/Attach a file - (max. 3)( pdf):
Please make sure that your attached file should not include any special character
When uploading multiple files they
must be selected at the same time from the same location eg. your Desktop.

Required!

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