Referral to RDNS HomeCare
Fax: 1300 768 296
Client Details:				
Name:	 <<Patient Demographics:Full Name>>			
Address	<<Patient Demographics:Full Address>>			
Phone:	<<Patient Demographics:Phone (Home)>>  m() <<Patient Demographics:Phone (Mobile)>>	Date of Birth:	<<Patient Demographics:DOB>>	
Next of kin/contact:	<<Next of kin or contact person>>	Phone: 	<<Next of kin or contact person, Phone>>	
Interpreter Required:	<<Interpreter required>>	Language spoken: 	<<Spoken Language at home>>	
Diagnoses:	<<Brief Diagnoses>>

Relevant past history:	 <<Clinical Details:History List>>	
Allergies:	 <<Clinical Details:Allergies>>	
Pension/DVA number:	  <<Patient Demographics:Pension Number>>  <<Patient Demographics:DVA Number>>	
Client is aware of referral:	  <<Patient is aware of Referral>>	

Referrer Details:		
Note: It is RDNS Homecare's practice to send GPs a brief note notifying you of the client's primary nurse and the outcome of our initial assessment.		
  
<<Doctor:Full Details>>	This Information has been faxed/Phoned:   <<This Referral will be faxed through>>	
Planned discharge date:  <<Planned discharge date if applicable>>	Requested first visit date: <<Requested first visit date>>	
Days you usually visit the client:   <<Days you usually visit the Patient>>	

RDNS Homecare Services/Care Requested:  (Mark as many as required)	
 q	Nursing assessment	 q	Stomal Therapy	 q	IV Therapy  *	 q	HIV/AIDS management	
 q	Continence management	 q	Personal Care	 q	Bowel Management  *	 q	Diabetes management *	
 q	Urinary catheter management *	 q	Aged care	 q	Medication management *	 q	Palliative nursing care	
 q	General nursing management	 q	Technical care *	 q	Pain management	 q	Wound Management	
q	Other: specify: 	
 * If you have requested an invasive procedure (eg. IV therapy, catheter management, wound care), please include or attach medical authorisation with specific details (eg. type and size catheter, specific wound regime). (Please include information about infections (eg. MRSA/VRE) 	
Additional Information: 

  q	Required equipment has been provided		q	I have included/attached medical authorisation	

Name: <<Patient Demographics:Full Name>>	Referral to RDNS HomeCare  (continued)	

Medical Authority to Administer Medicines: 	

<<Clinical Details:Medication List>>

GP Name:  <<Doctor:Name>>  		Signature:						Date: <<Miscellaneous:Date (short)>>	
<<.>> 
Relevant Information:	  Please advise if there is any actual or potential risk to RDNS HomeCare staff security	
Cognitive status:	 <<Cognitive status>>	
Continence:	  <<Continence>>	
Mobility:	 <<Mobility>>	
Client safety issues:	 <<Patient Safety Issues>>	
Carer:	 <<Carer>>	
At risk:	 <<At Risk>>	
Access to home:	 <<Access to home>>	
Other:	  <<Other relevant Information>>	
<<_>>
Referrals already made to other services:	
Local Government:	 q	Home help		q	Respite		q	Personal care	
	 q	Home maintenance	q	Other:	
		
Allied Community Health:	 q	Community Health Nurse		q	Occupational Therapist		q Physiotherapist	
	 q	Social Worker			q	Other	
		
ACAS (give details):		
MAPS/PGAT (give details):		
Day centre (give details):		
P.A.C:		
Other:	 	

Referrer: 	

GP Name:  <<Doctor:Name>>  		Signature:						Date: <<Miscellaneous:Date (short)>>