Medical
Palliative Care Referral Form
📝

Palliative Care Referral Form

1
Identify the patient requiring palliative care
2
Gather relevant patient history and medical records
3
Evaluate the patient's condition
4
Consultation with primary doctor
5
Approval: Primary Doctor
6
Prepare the referral form
7
Completion of the patient's demographic section
8
Completion of the medical information section
9
Discuss palliative care options with the patient
10
Discuss palliative care options with the patient's family
11
Authorization sign-off by the patient or legal guardian
12
Approval: Patient Consent
13
Document the decision-making process in medical records
14
Submit the form to the Palliative Care team
15
Approval: Palliative Care Team
16
Schedule initial visit with the Palliative Care team
17
Communicate the scheduled visit date with the patient
18
Follow up on the referral process
19
Close the referral process