POAC Service Requisition

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 IV Therapy (maximum once daily dose) Home Nursing Visit
Patient has been assessed as requiring dementia level of care *

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:

No preference Preference indicated below Booking confirmed at facility indicated below
Residential Care Facility
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 has not been contacted - POAC to contact and discuss with GP.
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 With partner only With family No fixed abode
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
Concerns/risks

Functional decline Falls risk Delirium Dementia Mental health concerns Mild cognitive impairment Isolation required Patient required a watch during hospital admission
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 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

Family (or self) transporting 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
Should be Empty:

POAC SERVICE REQUISITION

REFERRER INFORMATION

PATIENT DETAILS

CLINICAL HISTORY

SERVICES REQUIRED

Home Support Services

Intravenous Therapy