Download IF Referral Form - St Mark`s Hospital

Intestinal Failure & Nutrition Referral Form
This form must be completed in full and emailed/ faxed to the following:
Email: [email protected]
Fax: 0208 235 4009
Please complete all sections of the form. Please note that incomplete or ineligible forms will
be returned.
If you are faxing the forms please draw on the diagrams. For emailed forms please make detailed notes next to
the diagrams.
Patient Information
Title:
Patient Forename:
Patient Surname:
Home Address:
Postcode:
NHS Number:
Date of Birth:
Gender: Male/ Female
Tel:
Mobile:
Email:
Patient’s present location:
1) An inpatient on ………………………………. Ward at …………………………………………….. Hospital
Hospital Swtichboard Number: …………………………………… Ward extension:……………………………..
Doctor’s Bleep Number: …………………………………………….
2) Other (please specify): …………………………………………………………………………………………….
General Practitioner Information
Name of GP:
GP Address:
GP Telephone number:
Postcode:
Referring Doctor Information
Name of Doctor Completing Form:
Name of Consultant:
Specialty:
Referring to:
Medical □
Named:
Secretary Tel:
Surgical □
Reason for Referral
□ Complex access issues (inc fistuloclysis)
□ Initiation/ training of new home PN patient
□ High output stoma/fistula despite standard care
□ PN with metabolic/ psychiatric co-morbidity/ complications
□ Other (describe below)
□ Surgical re-appraisal
□ Surgical reconstruction
Please state if you would like us to
take over surgical care
Cause of Intestinal Failure
Please include key medical and surgical events (attach additional information)
Previous Operations
Please list ALL relevant operations and attach operation notes
Date (dd/mm/yy)
Operation
Presumed Anatomy
Please record areas resected, length of each part of
remaining SB and location of any strictures or areas of
known disease eg Crohn’s
Co-morbidities
Please describe severity e.g. Echo findings, FEV1, eGFR, HbA1C
□ Cardiac …………………….. □ Respiratory …………………… □ Neurological ……………….
□ Renal/ Uro ………………… □ Hepatic ……………………….. □ Endocrine ………………….
□ Psych ……………………… □ Haem inc. VTE ………………..
□ Other (use space for more detail)
Pressure Sores: ………………………………………………………………………………………….
Mobility: Bed bound □
Mobilising with aid □
Mobilising independently □
Please specify what aid: ……………………………………………………………………………………
Enterocutaneous Fistula (e) and Anatomy
□ From SB
□ From colon □ Other
(detail) Output
..………. ml/24hours
Bowel length proximal to fistula: □ Unknown
Known = ………… cm
□ Laparostomy wound
□ Gastrostomy tube
□ Persistent intra-abdominal sepsis
Current Route(s) of Nutrition
Tick all in use – please attach current PN prescription (including details of volume, N2, Glucose,
Calories, Lipid, Sodium and Magnesium. Please liaise with your dietitian
□ Oral
□ NG
□ NJ
□ Parenteral
Percutaneous:
□ gastrostomy
□ jejunostomy
□enteroclysis
Anthropometry:
Date measured ………………
Weight
………kg
BMI: ……..
Weight loss……. kg over …………
Oedema
□Y
□N
Venous Access
Please liaise with your Nutrition Nurse Specialist
□CVC:
Tunnelled □Y □N Cuffed □Y □N
□Implanted port
□PICC
□None of these
Lumens 1 2 3 4 5 Site (□ R □ L) (□ IJV □ SCV □ Fem)
Date inserted ………………
Line tip position: ………………….
Are any veins thrombosed? □N □Y Detail:……………
Investigations (all Radiology & Histology)
Please include dates and key findings
Blood Results
Date Measured: …………/…………./…………
HB
Na+
Bili
+
MCV
K
ALT
WCC
Ur
ALP
PLT
CR
ALB
Ca2+
PO42+
Mg2+
CRP
ESR
Ferritin
B12
Folate
Medications
Including anticoagulation, insulin, subcut infusions
Drug
Dose
Route
Frequency
Allergies: ………………………………………………………………………………………………………
Are there any non-clinical issues we should be aware of?
…………………………………………………………………………………………………………………….
Referring Consultant
If following a period of stay at St Mark’s, this patient is unable for any medical or social reasons to return
home/ into a suitable placement I agree to readmit him/ her back to this hospital
Form completed by:
Name (PRINT): ……………………………
Signature:……………………….
Phone Number: …………………………..
Date: ……………………………
PLEASE ENSURE THAT THE PATIENT IS AWARE THAT THEY WILL UNDERGO A PERIOD OF
ASSESSMENT AND CAN EXPECT A STAY OF ATLEAST 6-8 WEEKS. ANY SURGERY WILL NOT BE
PERFORMED ON THEIR INITIAL ADMISSION TO THE INTESTINAL FAILURE UNIT.
Patient Signature:
Date:
Patient Registration Form
PERSONAL DETAILS:
SURNAME: ________________ _____
TITLE:
Mr □
Mrs □ Miss □ Ms □
FORENAME: _________________________
Other □
STATUS: Single □ Married □ Widowed □ Divorced □
DATE OF BIRTH: ____/_____/______
SEX: Male □
Female □
ADDRESS: __________________________
HOME TELEPHONE:_______________________
__________________________________
MOBILE TELEPHONE:_____________________
__________________________________
WORK TELEPHONE:_______________________
POSTCODE: _________________________
EMAIL:_________________________________
GP DETAILS:
NAME OF GP:__________________________________
ADDRESS:
____________________________________
NHS NUMBER:_________________________________
____________________________________
TELEPHONE:___________________________________
____________________________________
FAX:_________________________________________
POSTCODE:___________________________
NEXT OF KIN DETAILS:
ADDRESS: __________________________
NAME: ________________________________
__________________________________
RELATIONSHIP:__________________________
__________________________________
TELEPHONE:____________________________
POSTCODE: _________________________
MOBILE:____________________________
ETHNIC GROUP:
White –
WHY WE ARE ASKING PATIENTS TO RECORD
THEIR ETHNIC GROUP
Black –
Any Other Background
□
Any Other Background
□
British
□
African
□
Irish
□
Caribbean
□
The North West London Hospitals NHS Trust
serves a multi-ethnic and multi-cultural
population. The recording of patient’s ethnic
group is necessary for the following reasons:
To identify who is currently using our services
and whether those services are accessible to
people from different ethnic groups.
Mixed –
Asian –
Any Other Background
□
Any Other Background
□
White & Asian
□
Bangladeshi
□
White & African
□
Indian
□
White & Caribbean
□
Pakistani
□
To check whether any particular groups are over
or under represented within any part of the
service
To help identify patterns of illness and need
among different ethnic groups
WHO HAS ACCESS TO THIS INFORMATION?
An individual’s details are STRICTLY CONFIDENTIAL.
Access to all information will be restricted to staff involved in
your direct care.
To stimulate and guide staff awareness of and
respond to the varied customs, beliefs and needs
of different ethnic groups.
Patient Signature: _________________________