HPC-EoL Communication Form


Main Critical Diagnosis:

Instructions for making a Palliative Care Referral:
Complete all five of the forms highlighted in blue and fax them to BOTH Home Care (604 702 4801) and Palliative Care (604 701 3637).
Fax a copy of the Palliative Care Benefits to Victoria and give the patient copies of the DNR and EoL Care Plan.
(The EoL Care Plan is optional, but will facilitate the billing of 14063, the code for palliative care planning.)

Collaborative Care Notes

Date Who was present? Issues/Outcomes Followup

Assessment   

Date Pain Dyspnoea Constipation PPS Wt Other

Palliative Care Contact No's:   Fax 604 701 3637

Clerk

Lorill Britz

Ph:795 4141    ext   612718

Nurse

Kim Giesbrecht

Ph:795 4141    ext   612719

Cell: 316 0996

Social Worker

Cindy Nichol

Ph:795 4141    ext   612720

Cell: 316 2497

PPS Level

Ambulation

Activity Disease

Self care

Intake

Conscious level

100%

Full

Normal activity

Full

Normal

Full

90%

Full

Normal activity

Full

Normal

Full

80%

Full

Normal activity

Full

Normal/reduced

Full

70%

Reduced

Decr activity

Full

Normal/reduced

Full

60%

Reduced

Minimal activity

Occ assistence

Normal/reduced

Full/confusion

50%

Sit/Lie

Minimal activity

Considerable help

Normal/reduced

Full/confusion

40%

Mainly bed

Minimal activity

Mainly help

Normal/reduced

Full/drowsy

30%

Total bed

Minimal activity

Total care

Reduced

Full/drowsy

20%

Total bed

Minimal activity

Total care

Minimal sips

Full/drowsy

10%

Total bed

Minimal activity

Total care

Mouth care

Drowsy/coma

0%

Death

-

-

-

-

Subject: