Community Nursing Referral							Fax  03 4215 7795

GP Referral
		Referral Date: Miscellaneous.Date

Feedback Requested:  Yes	

COMMUNITY NURSING REFERRAL

Tel: 1300 715 673

Fax: 03 4215 7795

		Referring General Practitioner:
Treating Doctor.Name
Address: Practice.Address
HPI-O:  
Ph: Practice.Phone
Fax: Practice.Fax
Provider No.: Treating Doctor.Provider Number
HPI-I: 

Consumer details:
Name: Patient Demographics.Full Name
Date of Birth:.Patient Demographics.DOB
Age:.Patient Demographics.Age
Sex: Patient Demographics.Gender
Title: Patient Demographics.Title
IHI:  Patient Demographics.IHI Number
ATSI:    Patient Demographics.ATSI Status
		Contact Address:
Patient Demographics.Full Name
Patient Demographics.Full Address
Tel (H): Patient Demographics.Phone (Home)
Tel (M): Patient Demographics.Phone (Mobile)
Email: Patient Demographics.E-mail
Alternative Contact: 

Interpreter required: Interpreter required		DVA Number: Patient Demographics.DVA Number	
Preferred language is: Language required		Medicare Number: Patient Demographics.Medicare Number	
Pension Card Number: Patient Demographics.Pension Number		Private Health Insurance:Patient Demographics.Health Fund Member Number 	

Date patient consented to referral:  Miscellaneous.Date	
Consent to share information:  Share information	
Consent to MBS bulk billing clinic if available:  MBS clinic	

Clinical Information: Patient Demographics.Full Name DOB: Patient Demographics.DOB

Please consider Telehealth for this patient:  Telehealth option

HealthPathways provides guidance in patient assessment, management and referral. 
HealthPathways	

Note

Reason for patient referral: 
Service requested
Additonal Informatio	
Warnings: Clinical Details.Warnings
Allergies: Clinical Details.Allergies	

Current Medication:
Clinical Details.Medications - Current Regular	
Social History:
Clinical Details.Social History
Clinical Details.Smoking
If yes to smoking, has cessation program been discussed?:  Smoking cessation	
Past Medical History: 
Clinical Details.Problem List (Resolved) With Comments	
Current Medical History:
Clinical Details.Problem List (Current) With Comments	

Clinical Information: Patient Demographics.Full Name DOB: Patient Demographics.DOB

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	FREQ	ROUTE	DATE TO BE CEASED	
Miscellaneous.Date						
Miscellaneous.Date						
Miscellaneous.Date						

Routine Insulin Orders:

DATE	 INSULIN	UNITS	FREQ	TIME	ROUTE	DATE TO BE CEASED	
Miscellaneous.Date					SUBCUT		
Miscellaneous.Date					SUBCUT		
Miscellaneous.Date					SUBCUT		
Miscellaneous.Date					SUBCUT		
Miscellaneous.Date					SUBCUT		

Correction doses:

DATE	PRE-MEAL BLOOD GLUCOSE	INSULIN	ADDITIONAL DOSE	ROUTE	DATE TO BE CEASED	
Miscellaneous.Date				SUBCUT		
Miscellaneous.Date				SUBCUT		
Miscellaneous.Date	> 20 mmol/L			SUBCUT		

Contact: Treating Doctor.Name

Doctor's Signature: _____________________________________ (Please sign here for above orders to be given by nursing staff)
Treating Doctor.Name
Date: Miscellaneous.Date

Clinical Information: Patient Demographics.Full Name DOB: Patient Demographics.DOB

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	FREQ	ROUTE	DATE TO BE CEASED	
Miscellaneous.Date						
Miscellaneous.Date						
Miscellaneous.Date						

Doctor's Signature: _____________________________________ (Please sign here for above orders to be given by nursing staff)
Treating Doctor.Name
Date: Miscellaneous.Date

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