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North Manchester District Nursing Team Referral Form All relevant sections of the form must be completed. This form is for patients who meet the District Nursing Home visiting criteria, mobile patients should be referred to treatment room. Authorisation for Drug Administration must be completed (page 2) If a visit is required within 24 hours please telephone the District Nursing Team District Nurse Teams Name of referrer: Team Cheetham Telephone 0161 202 8763 Fax 0161 202 8799 0161 205 0516 ( weekend) Neighbourhood 1 0161- 8612405/2417 0161 203 5777 0161 861 2505 0161 203 5962 Cornerstones 0161 230 2220 0161 230 2259 Harpurhey (Blackley) Telephone of Referrer: Date Referral: Neighbourhood 2 Victoria Mill Designation: Neighbourhood 3 Ward/ Location: Neighbourhood 4 Eve & Night 0161-795-4567 0871-550-0079 Date First Visit Required: 0161 625 8321 Patients name: Address: Patient Label GP practice: Are there safeguarding issues? Tel No: Home : Mobile Does visiting this patient present any risks? Postcode: Does patient have a key safe? Number? NHS No: Next of Kin: Carer details: Relationship: Relationship: Tel No: Tel No: Reason for Referral (***If Medication administration-Fax Authorisation***) Allergies? Relevant information/past medical history including past and planned treatment Pressure Sore/Wound Care (if required) – Patient must have 3 days of dressings on discharge Yes □ No □ Site Grade Moisture Duration Treatment Photo Clinical Lesions Y/N Incident Y/N Catheter Care ( if required) – Please also send urology pathway Yes □ No □ Reason for Catheter Date TWOC due Short term / Long term Catheter Home pack given Y/N Palliative Care - ( if required) Anticipatory Drug Prescribing form should be attached Yes □ No □ DNAR sent with patient Y/N / N/a Anticipatory Drugs Provided? Y/N Patient aware? Family Aware? 1 DN referral October 2016; Review Date April 2018 AUTHORISATION FOR DRUG ADMINISTRATION District Nurses are not able to administer patient medications without completed authorisation Please affix Patient label Date Drug Name Dosage Route Frequency Duration Start Date Team Harpurhey/Blackley Cornerstones Cheetham Telephone 0161- 861-2405/2417 0161 230 2220 0161 202 8763 Fax 0161 203 5777 0161 230 2259 0161 202 8799 Victoria Mill Eve & Night 0161 861 2505 0161 795-4567 0161 203 5962 0161 625 8321 End Date Doctor/Prescribers Signature 0161 205 0516 ( weekend) 2 DN referral October 2016; Review Date April 2018
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