POAC Service Requisition

COVID-19 SCREENING:

For screening of asymptomatic patients prior to respite admission, RAT is preferred test, as PCR may significantly delay the admission process.
Covid-19 Mandatory Assessment *

COVID-19 swab confirmed negative (RAT or PCR) Pending PCR swab result COVID-19 recovered, cleared by ARPHS or DHB Medical Officer (attach letter where available) Home Supports Only - swab not required, notify if current COVID positive, household contact or probable case POAC ADMIN USE ONLY
POAC SERVICE REQUISITION
I, the referrer, confirm the following: *

The patient and/or family has been fully informed and consented to this referral The patient is eligible for publicly funded health services in New Zealand
Patient DHB domicile *

ADHB CMDHB WDHB
Date *

Day Month Year
Date
Service request

Rest Home Private Hospital Secure Dementia Unit Home Supports/Personal Care Home Nursing Visit
DELAYS DURING OMICRON OUTBREAK

Due to the Omicron outbreak, many Aged Residential Care facilities are currently unable to accept admissions.

Placement may not be possible on the same day, and in some instances, there may be significant delays in finding a suitable facility able to accept admission.

Please consider alternative arrangements where possible (including Home-Based Support or family support) and ensure a plan is in place to manage patient safety pending confirmation of placement.
Has the patient recently tested positive for COVID-19? *

Yes No
Date tested positive *

Day Month Year
Date
IMPORTANT NOTE REGARDING DELAY IN SERVICE COVID-19 POSITIVE CARE:

Patients confirmed COVID-19 positive must NOT be discharged from the hospital until direct confirmation that services can be provided. Geneva will make direct contact with the referrer as soon as possible.

If the patient is currently at home, ensure that patient safety is prioritised pending confirmation of services.
Patient has been assessed as requiring secure dementia level of care and supporting geriatrician documentation attached/faxed (referral cannot proceed if supporting documentation not attached). *

Yes No
Sorry, we are unable to proceed for the following reason:

This option is only available where a level of care assessment has been completed and patient has been confirmed as requiring secure dementia level of care.

Please call POAC to discuss (09) 535 7218
Is this referral related to an injury under ACC? *

Yes No
Please refer to ACC for home-based support services. Use ACC705 form for DHB referral.
Residential care facility preference:

Booking confirmed at facility indicated below Booking pending at facility indicated below POAC to arrange facility
Residential Care Facility
Between 15th and 29th April due to critical staffing levels
Provider email contact
if known
Nursing Agency
Home Care Provider *
REFERRER INFORMATION
Referred by *

General Practice Hospital Hospice Urgent Care St John Residential Care
Designation *

Doctor Registered Nurse Nurse Practitioner Social Worker
Name of referrer/contact person *

First Name Last Name
Referring organisation *
Ward *
Contact phone *
Contact email *
To receive email confirmation of referral submission
GP Informed *

GP/Practice has been informed and consented and can be contacted as required GP/Practice has been informed and consented but not available to visit
GP Practice Email
PATIENT DETAILS
Patient name *

First Name Last Name
NHI *
Date of Birth *

Day Month Year
Gender *

Male Female
Ethnicity *
Patient address *
Home access
Please describe any issues to accessing home, directions, dogs or entry instructions
Living situation *

Lives alone Lives with partner Lives with family/friends No fixed abode Boarding facility Resides in Aged Residential Care
Patient contact details *
NOK name(s) and contact details *
Best contact person and phone number(s)
Best contact person to discuss supports

Patient NOK/EPOA
CLINICAL HISTORY
Patient GP name and phone
If different from referring clinician
Current diagnosis and reason for referral *
Relevant active medical problems *
List of medications/known allergies
Patient is on medications requiring regular follow up by GP during this stay and GP has been advised (referral cannot proceed if GP not advised) *

Yes No
Concerns/risks *

None applicable Functional decline Falls risk Mild cognitive impairment Delirium Dementia (please state behaviours) Wanders or risk of wandering Mental health concerns (please state) Isolation required (please state reason) Patient required a watch during hospital admission but has been without watch for 48 hours without incident (referral cannot proceed if patient still requiring watch) Patient weight >130kg
Mental health summary *
Please describe any relevant mental health history, current health state or concerns, including any risk to self or carer
Mobility

Fully independent With assistance Mobilising with use of stick/cane/crutch Mobilising with walker/frame Wheelchair Fully bed bound
Continence *

No known issues Bladder incontinent Bowel incontinent Catheter Stoma
SERVICES REQUIRED
Home Support Services
Services required:

Showering assistance Dressing Meal preparation Medication prompting Wellness check
Initial funded date *

Day Month Year
Date
Final funded date *

Day Month Year
Date
Total days/nights funded *
How many days in total will be required?
Number of hours required daily *
How many hours of care will be required each day. This may be an estimate and can be split across multiple visits. This will be discussed with patient and/or NOK. Minimum of 1 hour per visit.
Total maximum number of hours funded by POAC for this episode *
Tasks required at each visit *
Please describe in detail the tasks required at each visit (e.g showering assistance, meal preparation, medication prompting)
Plan following POAC care *
Please indicate the plan of care following POAC completion. (e.g. NASC assessment, DHB supports, family taking home, return to normal care)
Intravenous Therapy
- All medication is to be supplied

- Daily dose medication only

- Signed prescription and discharge summary (or clinical notes) to be faxed to POAC 09 535 7154 or attached to referral
Antibiotic name
Dosage
Dosage frequency *
PICC Line *

Yes No
Line in situ *

Yes No
Check List *

Signed prescription Hospital discharge summary or clinical notes Medication supplied to patient
Additional information
Transport to facility

Independently arranged transportation Ambulance (hospital will arrange) Ambulance (POAC to arrange) Taxi Mobility transport (wheelchair)
Pick up location *
Access for ambulance crew *
Please provide details and instructions for collection, including any stairs, pets or other access issues
Patient will travel in ambulance by: *

Stretcher Chair
Weight of patient *
Requirement to book appropriate ambulance crew
Upload document (or email to referral@poac.co.nz

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Disclaimer: POAC takes no responsibility for omissions of/or incorrect information. It is the responsibility of the referrer and receiving facility to ensure transfer of accurate information.
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POAC SERVICE REQUISITION

REFERRER INFORMATION

PATIENT DETAILS

CLINICAL HISTORY

SERVICES REQUIRED

Home Support Services

Intravenous Therapy