Out of Hospital Care (OHC) Referral Form

Out of Hospital Care (OHC) Referral Form

 

 

Does the client consent to this referral?
Package required (please select all that apply)

Please complete for people being referred to the EoL Package only

Please indicate which stage the patient is in:
Advanced Care Directive
With whom?
Not for Resuscitation
Sex
Indigenous status
Is an interpreter required?
Marital status
Living arrangement
Abode type
Upon discharge home, will the client be able to manage independently for the next 48 hours?
Can the client be assessed independently?
If No, is there family/carer that can support with this assessment and have they been informed about the referral?
Does the client have a carer?
Is emergency contact the same as carer contact?
GP DETAILS

Services prior to hospital admission/or current service provider

Commonwealth Home Support Program (CHSP)
Home Care Package (HCP)
Transitional Aged Care Package (TACP)
Has the TACP completed?
National Disability Insurance Scheme (NDIS)
Mental Health Services
Palliative Care
Carer Respite or other Respite services
Is this still current?
Community Nursing/Allied Health
Is this still current?
Department of Veteran Affairs (DVA)
Is this still current?
Any other formal/informal supports?
Services requested (services will be negotiated within the constraints of the package, and needs of the client/carer at assessment, please do not agree to set hours)
Does the client require any equipment?
Has the equipment been provided?
Has the client been cleared for discharge by OT/Physiotherapist?
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