Download community cancer nurse specialist service referral form

The Community Cancer Nurse Specialist Team is accredited as
a Practice Development Unit (PDU)
COMMUNITY CANCER NURSE SPECIALIST SERVICE REFERRAL FORM
ROUTINE REFERRAL (Patient to be contacted within 24hr of referral acceptance) Fax: 01202 305052
URGENT REFERRAL (Patient to be contacted within 4hr of referral acceptance)
Tel: 01202 305051/3
Locality ……………………………………… Hospital: RBH
PATIENT DETAILS
NHS No:
Hospital No:
Name:
Gender: Male
D.O.B:
Address :
GP:
PHT
OTHER
……………….
Female
GP Address:
Postcode:
Contact No:
Tel No:
Identified risks to lone visiting:
Referrer’s Name:
Designation:
N.O.K. Name:
Contact Details:
Relationship to patient:
Location:
NOK contact details:
Date:
ELIGIBILITY CRITERIA FOR REFERRAL
(Additional referral guidance overleaf)
Please
√
Essential: (All must be ticked)
 Patient must be registered to a GP with a Bournemouth or Poole address
 Cancer diagnosis & TYPE: ……………………………………………………..
 18+ years
 Patient agrees to referral
 Be receiving an active cancer treatment (both curative + palliative)
Plus: Patient must have one or more of the following:
1.
2.
3.
4.
5.
6.
Experiencing a high level of anxiety or distress due to a cancer diagnosis
Experiencing side effects from treatment despite recommended intervention
Receiving a cancer treatment that could potentially be administered, or monitored in the community
Having problems with central venous access devices
At least one unplanned hospital admission, or contact, due to their cancer diagnosis or treatment
Requires additional support or information regarding their cancer diagnosis - at any stage
Other professionals involved:
Relevant PMH:
Brief cancer treatment history:
Expectations for referral:
CCNS use only: DATE REC’D…………………………………….TIME REC’D ……………………………………. DATE/TIME contacted …………………………………………
REFERRAL ACCEPTED:
Yes ………..
No ……………. (Reason)…………………………………... Action taken re declined ………………………………………..
The Community Cancer Nurse Specialist Team is accredited as
a Practice Development Unit (PDU)
COMMUNITY CANCER NURSE SPECIALIST SERVICE
REFERRAL CRITERIA
Essential Criteria overleaf must be met for all patients referred, plus have one or more
additional needs. Possible examples include:
1. Patients receiving cancer treatments of any type, but especially those at increased risk of
problems, for example, patients with cancers of the Head + Neck, Upper GI, high grade
Lymphoma, or receiving combination therapies, e.g. Chemo and Radiotherapy.
2. Those requiring additional support +/or information. This may include the need for further
assessment and consideration of other services, signposting or referring on.
3. Short-term or long-term toxicity related problems, could include nausea + vomiting, alterations
in bowel habits, mucositis, hand + foot syndrome.
4. This could include proactive monitoring the use of oral chemotherapy. Potential for home or
community clinic administration, for example, Platelet transfusions, IV bisphosphonates,
ambulatory chemotherapy, etc.
5. Concerns or issues experienced due to the patient having a central venous access device.
This relates to the patient/care, or queries, training needs of other health care professionals.
6. Any unplanned contacts or admissions which warrant follow-up to prevent further problems
Ensure tailored follow up + plan for additional support, admission avoidance or timely,
appropriate admissions.
7. General or specific patient-centred information pre-treatment, during treatment or after
treatment to promote survivorship and rehabilitation.
Acceptance of Referral (CCNS Service operates 0830hr – 1630hr Mon –Fri)
Routine referral
Please fax: 01202 305052
If referral accepted, patient will be contacted within 24 hours if possible.
Urgent referral
Please tel: 01202 305051/3 (Before 1600hr)
If referral accepted, patient will be contacted within 4 hours if possible.
Please ensure relevant and up-to-date contact details for the patient are specified on the referral.
The CCNS service is not an emergency service. Please continue to use the relevant secondary care
Open Access services regarding emergency issues, or urgent problems ‘out of hours’.
Acceptance onto Community Cancer Nurse Specialist Caseload
Patients may receive a one-off assessment, intervention or signposting, or, may be accepted onto the
CCNS caseload, either short-term or long-term, dependent upon need. Referrers will be notified of the
outcome.
PLEASE NOTE: The Community Cancer Nurse Specialist Team will continue to work closely with
their Specialist & Generalist Palliative Care colleagues. If there is any doubt over which team would
be the most appropriate for your patient, please ring either team to discuss further.
CCNS use only: DATE REC’D…………………………………….TIME REC’D ……………………………………. DATE/TIME contacted …………………………………………
REFERRAL ACCEPTED:
Yes ………..
No ……………. (Reason)…………………………………... Action taken re declined ………………………………………..