Out of Hospital Care (OHC) Referral Form

Step 1

Referral Information

Date

Facility/Local Health District

Medical Record Number (MRN)

Ward/bed no.

Does the client consent to this referral?

Yes No

Estimated date of discharge (not applicable if in the community)

Package required

ComPacks ComPacks/Healthy@Home (SNNSWLHD, SWSLHD, SESLHD and HNELHD only) ComPacks/Rapid Access to Care and Evaluation (WSLHD only) Safe and Supported at Home (SASH) End of Life (EoL)

Please complete for people being referred to the EoL Package only

With whom?

Step 2

Personal/Client details

Step 3

Hospital and referrer information

Reason for admission/relevant health issues

Referrer name

Contact phone number

Alternate staff contact

Alternate staff phone number

Email address

Upon discharge home, will the client be able to manage independently for the next 48 hours?

Yes No

Can the client be assessed independently?

Yes No

Does the client have a carer?

Yes No

Step 4

Client emergency/alternate contact

Is emergency contact the same as carer contact?

Yes No

GP Details

Phone

Suburb

Step 5

Services prior to hospital admission/or current service provider

Step 6

Allied health/equipment

Does the client require any equipment?

Yes No

Has the equipment been provided?

Yes No

Has the client been cleared for discharge by OT/Physiotherapist?

Yes No

Additional information

Please note the time of submission so we can respond to your referral promptly.

Name of the person submitting the form

Email address to send confirmation

Summary