FAX ONLY TO 03 4215 7795
GP Referral
		Referral Date: <TodaysDate>

Feedback Requested:  Yes	

COMMUNITY NURSING REFERRAL

Tel: 1300 715 673

Fax: 03 4215 7795
		Referring General Practitioner:
<DrName> 
<Practice>
<UsrAddress>
HPI-O: <PracHPIO>
Phone: <UsrPhone>   Fax: <UsrFax>
Email: <DrEmail>
Provider No.: <DrProviderNo>
HPI-I: <DrHPII>	

Consumer details:
Name:	<PtFirstName> <PtSurname>
Date of Birth:	<PtDoB>
Age:                        <PtAge>
Preferred Name/s:	<PtPrefName>
Sex:	<PtSex>
Title:	<PtTitle>
Pt IHI:                     <PtIHI>
		Contact Address:	<PtName>
	<PtStreet>
	<PtCity>  <PtState>    <PtPostcode>
Phone:	<PtPhoneH>
Work:	<PtPhoneWk>
Mobile:	<PtPhoneMob>
Email:	<PtEmail>

Alternative Contact: 

 
Interpreter required: <Does the patient require an interpreter?>		DVA Number: <PtDVANo>	
Preferred language is: <If interpreter needed, which language>		Insurance: <PtHealthIns>	
Pension Card Number: <PtPensionNo>		Medicare Number: <PtMCNo>	

Clinical Information:		<PtFirstName> <PtSurname> DOB:  <PtDoB>

HealthPathways Barwon provides guidance in patient assessment, management and referral. 
 			<HealthPathways Barwon guidance in Mx Ax referral>	

<Community Nursing Referrals>

Reason for patient referral: 
<Service requested?>
 
<Additional Information>

 <Reactions> 
Warnings:  <Comment>
Current Medication:  <CurrentRx>
Social History:  <SocialHx> 
Past Medical History: <PMHAll>

Clinical Information:		<PtFirstName> <PtSurname> DOB:  <PtDoB>

Allergies and adverse drug reactions:  <Reactions> 

Medication Authority to administer Medicines:
(This section is to record only medications to be dispensed/administered by nurse)
(Legible handwriting or typed orders please)

DATE	MEDICATION	DOSE	FREQUENCY	ROUTE	DATE TO BE CEASED	
<TodaysDate>
						
<TodaysDate>
						
<TodaysDate>

Routine Insulin Orders:

DATE	INSULIN	DOSE (UNITS)	FREQ	TIME	ROUTE	DATE TO BE CEASED	
<TodaysDate>
					SUBCUT		
<TodaysDate>
					SUBCUT		
<TodaysDate>
					SUBCUT		
<TodaysDate>
					SUBCUT		
<TodaysDate>
					SUBCUT		

Correction doses:

DATE	PRE-MEAL BLOOD GLUCOSE 	INSULIN 	ADDITIONAL DOSE (UNITS0 	ROUTE	DATE TO BE CEASED	
<TodaysDate>
	
			SUBCUT		
<TodaysDate>
				SUBCUT		
<TodaysDate>	> 20 mmol/L	

		SUBCUT		

Contact:  <DrName>   <Practice:Phone>

Doctor's Signature: __________________________________  (Please sign here for above orders to be given by nursing staff)
<DrName>
Date: <TodaysDate>

Clinical Information:		<PtFirstName> <PtSurname> DOB:  <PtDoB>

Reportable levels: (Reference User Guide to Insulin - National Safety Quality Council)

Suggested reportable levels 

I agree with the suggested reportable levels   Yes    No ›  (If no, delete or adjust the following as required)

Clients to use their own meters
Blood glucose <   4 mmol/L        	
Blood glucose > 20 mmol/L
Two consecutive BGL > 16 mmol/L
Three consecutive BGL > 12 mmol/L
If BGL > 15 in T1DM and ketones > 0.6
If unwell T1DM and ketones > 0.6
If BGL > 20 in T2DM and ketones > 0.6

Syringe Driver or Infusion Device:

DATE	MEDICATION	DOSE	FREQUENCY	ROUTE	DATE TO BE  CEASED	
<TodaysDate>

<TodaysDate>
						
<TodaysDate>
						
<TodaysDate>

Doctor's Signature: __________________________________  (Please sign here for above orders to be given by nursing staff)
<DrName>
Date:  <TodaysDate>

 		Did HealthPathways website assist in assessment, management or referral of your patient?  <Did HPW assist in Ax, Mx or referral of your pt?>