Personal Details
Surname Click or tap here to enter surname.	Forenames Click or tap here to enter forename.	CHI Number Click or tap here to enter CHI Number.	Age Enter age	Gender Choose Gender.
Address Click or tap here to enter address.	Post Code Click or tap here to enter Post Code.	Phone Click or tap here to enter phone number.

2.Next of Kin Details
Name Click or tap here to enter name.	Patient Relationship Choose relationship.	Address Click or tap here to enter address.	Post Code Click or tap here to enter Post Code.
NoK Phone Click or tap here to enter phone.	Does patient live alone?	Is NoK aware of referral?	Who should initial contact be with? Choose initial contact.

3.Current Care
Patient Location	Hospital	Consultant	Ward	Phone Number
Choose location.	Click or tap here to enter Hospital.	Click or tap here to enter Consultant.	Click or tap here to enter Ward.	Click or tap here to enter phone.
SERVICES CURRENTLY INVOLVED IN CARE (where applicable)
Hospital Palliative Care Team	Community Palliative Care Team	Community/District Nurse	Other Nurse Specialist Team
Named Professional Click or tap here to enter text.	Named Professional Click or tap here to enter text.	Named Professional Click or tap here to enter text.	Named Professional Click or tap here to enter text.
Contact details Click or tap here to enter text.	Contact details Click or tap here to enter text.	Contact details Click or tap here to enter text.	Contact details Click or tap here to enter text.
GP Practice Click or tap here to enter text.	GP Phone Click or tap here to enter text.	Current Care Package Click or tap here to enter text.

4. Referral Service
Choose Referral Service.
REFERRAL REASON (IPU Referrals Only)	☐ Symptom Control	☐Rehabilitation	☐ End of Life Care

5. Medical Information & Consents
Main Diagnosis	Diagnosis Date
Click or tap here to enter text.	Click or tap to enter a date.
Clinical Details	Past Medical History	Brief Summary of Referral Reason (incl physical & psychological symptoms, social circumstances)
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Current Mobility Level	Palliative Performance Scale	Phase of Illness
Choose an item.	Choose an item.	Choose an item.
Additional Mobility Information (incl requirements for additional equipment, communication aids and mobility aids)	Preferred Hospice
Click or tap here to enter text.
Consents
Has patient consented to referral?	Does patient lack capacity to consent? (Adult with Incapacity (Scotland) Act 2000)	If Yes, has Welfare Power of Attorney consented to referral?
Does the patient smoke?	If Yes, is the patient aware of the Hospice No Smoking Policy?

6. Medication Details (Complete for IPU Referrals)
Current Medications	Relevant Medication History	Allergies & Intolerances
Click or tap here to enter medications.	Click or tap here to enter medication history.	Click or tap here to enter allergies & intolerances.

7. Anticipatory Care Plan (COMPLETE for IPU REFERRALS)
Patient for Resuscitation?	Resus Status discussed with patient/NoK?	ReSPECT form in Place?
Patient aware of diagnosis/likely prognosis?	Family/NoK aware of diagnosis/likely prognosis?	Additional Info on RESUS and ACP
Click or tap here to enter RESUS & ACP Discussion.
Preferred place of care (MANDATORY)	Preferred Place of Death (MANDATORY)	Discussion Details (PPC & PPD)
Choose PPC.	Choose PPD.	Click or tap here to enter PPC & PPD Discussion summary.

8.Referrer Details
Name Click or tap here to enter text.	Designation Click or tap here to enter text.	Address Click or tap here to enter text.	Post Code Click or tap here to enter text.
Contact Phone Click or tap here to enter text.	eMail Address Click or tap here to enter text.	Referral Date Click or tap to enter a date.	Triager completing referral Click or tap here to enter text.

9. Responding to Urgency of Need in Palliative Care (RUN-PC) Triage Tool
Type or Select Date.	Type or Select Date.	Type or Select Date.

1. Physical distress of patient Unknown 0 Nil 0 Mild 0 Moderate 14 Severe 32	Choose score.	Choose score.	Choose score.
2. Psychological or spiritual suffering of patient Unknown 0 Nil 0 Mild 0 Moderate 6 Severe 14	Choose score.	Choose score.	Choose score.
3. Distress or burnout of caregiver Unknown 0 Nil 0 Mild 0 Moderate 5 Severe 13	Choose score.	Choose score.	Choose score.
4. Urgent and complex communication or information needs of patient or caregiver Unknown 0 Nil 0 Yes 8	Choose score.	Choose score.	Choose score.
5. Significant discrepancy between care needs and care arrangements Unknown 0 Nil 0 Impending 6 Current 10	Choose score.	Choose score.	Choose score.
6. Mismatch between current site of care and patient or caregiver’s desired site of care Unknown 0 No 0 Yes 9	Choose score.	Choose score.	Choose score.
7. Patient is imminently dying Unknown 0 No 0 Yes 14	Choose score.	Choose score.	Choose score.
Total (max 100) Right click to the left of the total then select ‘Update Field’	0	0	0
Initials	Click or tap here to enter initials.	Click or tap here to enter initials.	Click or tap here to enter initials.
Comments Click or tap here to enter text.

FOR HOSPICE USE ONLY
Date Received	Enter or select Date Received
Date Referral Meeting	Enter or select Date of Referral Meeting
Decision	Enter Referral Decision