Sunshine Coast Hospital and Health Service
(NQ45600007J)
 Nurse Navigator Generalist Referral Form
(BP V1.0, December 2020)

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Date of Referral: <TodaysDate>

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PATIENT DETAILS

RE: <PtFirstName> <PtSurname>
Preferred name: <PtPrefName>
Date of birth: <PtDoB>
Gender: <PtSex>
Address: <PtAddress>
Phone numbers: Home <PtPhoneH>  Mobile <PtPhoneMob> Work  <PtPhoneWk>
Email: <PtEmail>
Marital status: <PtMaritalSt>
Aboriginal or Torres Strait Islander origin: <Aboriginal or Torres Strait Islander?>
Ethnicity: <PtEthnicity>
Language spoken (if not English): <Language spoken (if not English)?>
Is an interpreter required: <Is an interpreter required?>

Emergency contact details: 
Name: <NOKName>
Relationship: <NOKRelation> 
Phone number: <NOKContact> 

Patient consent: <Is the patient aware of this referral?>
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PRIMARY REASON FOR REFERRAL – 
Tick all that apply

Chronicity: 
<Select criteria for referral - Chronicity>		

Complexity: 
<Select criteria for referral - Complexity>

Intensity and/or Fragility:	
<Select criteria for referral - Intensity and/or Fragility>
 
Additonal comments: <Additional comments>

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MEDICAL HISTORY

Active Medical History: 
<PMHActive>

Inactive Medical History:
<PMHInactive>

Medications:
<CurrentRx>

Main purpose for referral is for patient to receive:
 <Main purpose of referral is for patient to receive>   

Medical concerns or planned interventions:
 <Medical concerns/planned interventions>

Additonal referral information: (e.g. medical/family needs, ACAT assessed): <Additional info e.g. medical, family needs, ACAT>

Please attach applicable documents:
 <Please attach applicable documents>    
 
Current inpatient - estimated discharge date: <If current inpatient - estimated discharge date>
Hospital: <If current in-patient, which hospital?>
 
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REFERRING DOCTOR DETAILS

Name: <DrName>
Qualifications: <DrQualifications>
Provider No: <DrProviderNo>
Practice Name: <Practice>
Address: <UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>

Please list other professionals involved in care of this patient:
 <Other professionals involved in patient's care>

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VERIFICATION

Electronically Signed: <DrName>
<TodaysDate>

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SUBMITTING YOUR REFERRAL

Secure messaging via Medical Objects: Qhealth, Sunshine Coast Ambulatory Care Centre  (NQ45600007J)

If unable to send electronically, fax: 07 5205 0555 

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