WHISPAR
Wigan Healthier partnership Integrated Specialist Palliative care Active Response
We appreciate you may not have all the information requested- please note sections in bold are essential to process the referral if not completed be referral will be returned. Please provide as much information as you are able as this will ensure we get right services at the right time to the patient
Send all referrals to: wlhospice.admin@nhs.net
Referrer Details	
Referrer Name:		     
	Tel no:	     	
Referrer Job Role:	     
	
Referrer Organisation	     
	
If Discharge from Hospital

	Ward	     	Ward contact number	     	
	Date of discharge	     	Time of discharge	     	
Date Referral made	Long date letter merged 	
Does the patient have capacity	Yes  	No  	
If yes, how was consent gained for referral:	By patient 		If no, by the carer / family member    
	
PATIENT DETAILS	
Surname:
Surname 	Forename:
Given Name 	DOB:
Date of Birth 	
Home address:
Home Full Address (stacked) 
	Key Code: 
     	
Patient aware of diagnosis / prognosis:  
Yes       No  	Family aware of diagnosis / prognosis:  
Yes       No 	
Postcode:
Home Address Postcode 	Telephone no:
Patient Home Telephone / Patient Mobile Telephone 	Marital status:
Marital Status 	
NHS number:
NHS Number 	Ethnic group:
Ethnic Origin 
     	Religion:
Religion 
     	
Language: Main Language 
     	Interpreter required:  Yes       No  	

Any communication issues (including difficulty with hearing, eyesight, and speech, please specify:
     
	
NOK - Name:
     	NOK Relationship to patient:
     	NOK Tel no:
     	
GP Name:
Usual GP Full Name 	GP Practice:
Organisation Full Address (stacked) 
	GP tel no:
Organisation Telephone Number 	
Reason for referral - Please outline the main problems, concerns, and symptoms you would like the WHISPAR team to help with. (Please provide as much information as possible to ensure the referral is actioned appropriately.)	

     
     
     
     
     
     
     
     
     
     
	
Diagnosis and extent of disease:

     
     
     
     
     
     
	
Previous relevant medical history:

     
     
     
     
     
     
	
Important events and treatments:

     
     
     
     
     
     

Medication Information
	
Medication List:
Medication	
Known Allergies:
Allergies 	
Does the patient have an ICD (Implantable cardioverter defibrillator) in situ? Yes   No 	
Gold Standards Framework (GSF) coding / prognosis:	
Red (hours/days)         

        	Amber (weeks/ months)
	Green (months/year)
	
Does the patient have:	
EPaCCS record:     Yes    No  	uDNACPR:             Yes     No 	
SOI:                          Yes    No  	ACP:                       Yes     No 	
IPOC:                       Yes    No  	Anticipatory medications in place: 
Yes     No 	
Syringe pump in place: Yes     No 	Equipment in place, please specify:       
     
                              	
Preferred place of care:
Home  Hospice  Hospital  Other 
Not discussed 
	Preferred place of death:
Home  Hospice  Hospital  Other 
Not discussed 
	
Continuing Health Care funding agreed / in place:  
Yes     No 	If yes, was this agreed as a fast-track application: Yes     No  	
Is a package of care in place: please give details:

     
     
     	

Safety Considerations Are there any concerns regarding the patients or family members behaviours?	

     
     
     
     	
Other services involved:	
Name 	Contact name and contact details