{"id":33547,"date":"2023-11-04T07:08:03","date_gmt":"2023-11-04T07:08:03","guid":{"rendered":"https:\/\/www.process.st\/templates\/palliative-care-referral-form\/"},"modified":"2024-03-05T15:05:23","modified_gmt":"2024-03-05T15:05:23","slug":"palliative-care-referral-form","status":"publish","type":"post","link":"https:\/\/www.process.st\/templates\/palliative-care-referral-form\/","title":{"rendered":"Palliative Care Referral Form"},"content":{"rendered":"\n<section id=\"identify-the-patient-requiring-palliative-care\"> \n <h2>Identify the patient requiring palliative care<\/h2>\n <div class=\"text-content\">\n   This task involves identifying patients who require palliative care. It is important to determine the patient's needs and assess their eligibility for palliative care services. The outcome of this task is to identify patients who can benefit from palliative care and proceed with the referral process. \n <\/div> \n <div class=\"text-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Patient Name <\/label> \n   <input type=\"text\" placeholder=\"Something will be typed here...\" disabled class=\"form-control\"> \n  <\/div> \n <\/div> \n <div class=\"text-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Patient ID <\/label> \n   <input type=\"text\" placeholder=\"Something will be typed here...\" disabled class=\"form-control\"> \n  <\/div> \n <\/div> \n <div class=\"select-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Primary Diagnosis <\/label> <select disabled class=\"form-control\"> <option value=\"An option will be selected here\">An option will be selected here<\/option> <\/select> \n  <\/div> \n  <ul class=\"items\"> \n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       1 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Cancer \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       2 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Heart Disease \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       3 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Respiratory Disease \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       4 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Neurological Disorder \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       5 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Other \n    <\/div> <\/li> \n  <\/ul> \n <\/div> \n <div class=\"date-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Date of Identification <\/label> \n   <div class=\"date-container\"> <button type=\"button\" disabled class=\"btn btn-default\"> <i class=\"fa fa-calendar btn-icon\"><\/i> Date will be set here <\/button> \n   <\/div> \n  <\/div> \n <\/div> \n<\/section> \n<section id=\"gather-relevant-patient-history-and-medical-records\"> \n <h2>Gather relevant patient history and medical records<\/h2>\n <div class=\"text-content\">\n   In order to make an informed referral for palliative care, it is necessary to gather relevant patient history and medical records. This task involves collecting documents that provide insights into the patient's medical condition, previous treatments, and any relevant information that can support the palliative care referral process. \n <\/div> \n <div class=\"text-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Medical Record Number <\/label> \n   <input type=\"text\" placeholder=\"Something will be typed here...\" disabled class=\"form-control\"> \n  <\/div> \n <\/div> \n <div class=\"text-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Treating Physician <\/label> \n   <input type=\"text\" placeholder=\"Something will be typed here...\" disabled class=\"form-control\"> \n  <\/div> \n <\/div> \n <div class=\"file-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Medical Records <\/label> \n   <div class=\"file-container\"> <button type=\"button\" disabled class=\"btn btn-default\"> <i class=\"fa fa-upload btn-icon\"><\/i> File will be uploaded here <\/button> \n   <\/div> \n  <\/div> \n <\/div> \n<\/section> \n<section id=\"evaluate-the-patients-condition\"> \n <h2>Evaluate the patient's condition<\/h2>\n <div class=\"text-content\">\n   This task involves evaluating the patient's condition to determine the severity of their illness and their need for palliative care. It is essential to assess the physical, emotional, and social aspects of the patient's condition to provide appropriate care and support. \n <\/div> \n <div class=\"textarea-field-content form-field-content\"> \n  <div class=\"form-group\"> <label> Patient Symptoms and Complaints <\/label> <textarea placeholder=\"Something will be typed here...\" rows=\"3\" disabled class=\"form-control\"><\/textarea> \n  <\/div> \n <\/div> \n <div class=\"multi-choice-content form-field-content\"> \n  <div class=\"form-group\"> <label> Medical History <\/label> <select disabled class=\"form-control\"> <option value=\"\">Multiple options can be selected from this list<\/option> <\/select> \n  <\/div> \n  <ul class=\"items\"> \n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       1 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Diabetes \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       2 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Hypertension \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       3 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Cancer \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       4 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Heart Disease \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       5 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Other \n    <\/div> <\/li> \n  <\/ul> \n <\/div> \n <div class=\"multi-choice-content form-field-content\"> \n  <div class=\"form-group\"> <label> Functional Status <\/label> <select disabled class=\"form-control\"> <option value=\"\">Multiple options can be selected from this list<\/option> <\/select> \n  <\/div> \n  <ul class=\"items\"> \n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       1 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Independent \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       2 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Requires Assistance \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       3 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Bedridden \n    <\/div> <\/li> \n  <\/ul> \n <\/div> \n <div class=\"multi-select-content form-field-content\"> \n  <div class=\"form-group\"> <label> Assessment Tools <\/label> \n  <\/div> \n  <ul class=\"items\"> \n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       1 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Pain Assessment \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       2 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Depression Screening \n    <\/div> <\/li>\n   <li class=\"item\"> \n    <div class=\"step-number-container\"> \n     <div class=\"step-number\">\n       3 \n     <\/div> \n    <\/div> \n    <div class=\"step-checkbox-container\"> \n     <div class=\"step-checkbox\"><\/div> \n    <\/div> \n    <div class=\"item-name-static\">\n      Quality of Life Assessment \n    <\/div> <\/li> \n  <\/ul> \n <\/div> \n<\/section> \n<section id=\"consultation-with-primary-doctor\"> \n <h2>Consultation with primary doctor<\/h2> \n<\/section> \n<section id=\"approval-primary-doctor\"> \n <h2>Approval: Primary Doctor<\/h2>\n <div class=\"approval-content\"> \n  <div class=\"header\"> \n   <div class=\"list-title\">\n    Will be submitted for approval:\n   <\/div> \n  <\/div> \n  <div class=\"approval-rule-subject-tasks-list\"> \n   <ul class=\"list\"> \n    <li> \n     <div class=\"approval-rule-subject-tasks-list-item\"> \n      <div class=\"item\"> \n       <div class=\"container\"> <span class=\"title\">Consultation with primary doctor<\/span> \n        <div class=\"body\">\n         Will be submitted\n        <\/div> \n       <\/div> \n      <\/div> \n     <\/div> <\/li> \n   <\/ul> \n  <\/div> \n <\/div> \n<\/section> \n<section id=\"prepare-the-referral-form\"> \n <h2>Prepare the referral form<\/h2> \n<\/section> \n<section id=\"completion-of-the-patients-demographic-section\"> \n <h2>Completion of the patient's demographic section<\/h2> \n<\/section> \n<section id=\"completion-of-the-medical-information-section\"> \n <h2>Completion of the medical information section<\/h2> \n<\/section> \n<section id=\"discuss-palliative-care-options-with-the-patient\"> \n <h2>Discuss palliative care options with the patient<\/h2> \n<\/section> \n<section id=\"discuss-palliative-care-options-with-the-patients-family\"> \n <h2>Discuss palliative care options with the patient's family<\/h2> \n<\/section> \n<section id=\"authorization-signoff-by-the-patient-or-legal-guardian\"> \n <h2>Authorization sign-off by the patient or legal guardian<\/h2> \n<\/section> \n<section id=\"approval-patient-consent\"> \n <h2>Approval: Patient Consent<\/h2>\n <div class=\"approval-content\"> \n  <div class=\"header\"> \n   <div class=\"list-title\">\n    Will be submitted for approval:\n   <\/div> \n  <\/div> \n  <div class=\"approval-rule-subject-tasks-list\"> \n   <ul class=\"list\"> \n    <li> \n     <div class=\"approval-rule-subject-tasks-list-item\"> \n      <div class=\"item\"> \n       <div class=\"container\"> <span class=\"title\">Authorization sign-off by the patient or legal guardian<\/span> \n        <div class=\"body\">\n         Will be submitted\n        <\/div> \n       <\/div> \n      <\/div> \n     <\/div> <\/li> \n   <\/ul> \n  <\/div> \n <\/div> \n<\/section> \n<section id=\"document-the-decisionmaking-process-in-medical-records\"> \n <h2>Document the decision-making process in medical records<\/h2> \n<\/section> \n<section id=\"submit-the-form-to-the-palliative-care-team\"> \n <h2>Submit the form to the Palliative Care team<\/h2> \n<\/section> \n<section id=\"approval-palliative-care-team\"> \n <h2>Approval: Palliative Care Team<\/h2>\n <div class=\"approval-content\"> \n  <div class=\"header\"> \n   <div class=\"list-title\">\n    Will be submitted for approval:\n   <\/div> \n  <\/div> \n  <div class=\"approval-rule-subject-tasks-list\"> \n   <ul class=\"list\"> \n    <li> \n     <div class=\"approval-rule-subject-tasks-list-item\"> \n      <div class=\"item\"> \n       <div class=\"container\"> <span class=\"title\">Submit the form to the Palliative Care team<\/span> \n        <div class=\"body\">\n         Will be submitted\n        <\/div> \n       <\/div> \n      <\/div> \n     <\/div> <\/li> \n   <\/ul> \n  <\/div> \n <\/div> \n<\/section> \n<section id=\"schedule-initial-visit-with-the-palliative-care-team\"> \n <h2>Schedule initial visit with the Palliative Care team<\/h2> \n<\/section> \n<section id=\"communicate-the-scheduled-visit-date-with-the-patient\"> \n <h2>Communicate the scheduled visit date with the patient<\/h2> \n<\/section> \n<section id=\"follow-up-on-the-referral-process\"> \n <h2>Follow up on the referral process<\/h2> \n<\/section> \n<section id=\"close-the-referral-process\"> \n <h2>Close the referral process<\/h2> \n<\/section>\n","protected":false},"excerpt":{"rendered":"<p>Identify the patient requiring palliative care This task involves identifying patients who require palliative care. It is important to determine the patient's needs and assess their eligibility for palliative care services. The outcome of this task is to identify patients who can benefit from palliative care and proceed with the referral process. Patient Name Patient [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"ep_exclude_from_search":false,"cover_icon_emoji":"\ud83d\udcdd","cover_icon_url":"","tasks_count":"19","template_description":"","template_id":"nsfcd_egkhYOBG9G4xtH0g","task_0":"Identify the patient requiring palliative care","task_slug_0":"identify-the-patient-requiring-palliative-care","task_1":"Gather relevant patient history and medical records","task_slug_1":"gather-relevant-patient-history-and-medical-records","task_2":"Evaluate the patient's condition","task_slug_2":"evaluate-the-patients-condition","task_3":"Consultation with primary doctor","task_slug_3":"consultation-with-primary-doctor","task_4":"Approval: Primary Doctor","task_slug_4":"approval-primary-doctor","task_5":"Prepare the referral form","task_slug_5":"prepare-the-referral-form","task_6":"Completion of the patient's demographic section","task_slug_6":"completion-of-the-patients-demographic-section","task_7":"Completion of the medical information section","task_slug_7":"completion-of-the-medical-information-section","task_8":"Discuss palliative care options with the patient","task_slug_8":"discuss-palliative-care-options-with-the-patient","task_9":"Discuss palliative care options with the patient's family","task_slug_9":"discuss-palliative-care-options-with-the-patients-family","task_10":"Authorization sign-off by the patient or legal guardian","task_slug_10":"authorization-signoff-by-the-patient-or-legal-guardian","task_11":"Approval: Patient Consent","task_slug_11":"approval-patient-consent","task_12":"Document the decision-making process in medical records","task_slug_12":"document-the-decisionmaking-process-in-medical-records","task_13":"Submit the form to the Palliative Care team","task_slug_13":"submit-the-form-to-the-palliative-care-team","task_14":"Approval: Palliative Care 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