PRETORIA SUNGARDENS HOSPICE



MAMELODI HOSPICE

(SUNGARDENS)

SOS Children’s Village Unit 2, 21310 Sibande Street, Mamelodi East 0122

TEL NO: 010 446 3814

mamelodi@.za

CONFIDENTIAL MEDICAL REPORT FOR PALLIATIVE CARE

(To be completed by a Medical Officer)

1. IDENTIFYING PARTICULARS OF PATIENT

|Full name of patient | |

|ID Number | |

|Physical address | |

| |………………………………………………………………………………………. |

| | |

| |………………………………………………………………………………………. |

| | |

| |………………………………………………………………………………………. |

|Contact numbers |Home: |Cell: |

| | | |

2. REASONS FOR REFFERAL

|REASON |YES |COMMENTS |

|PAIN MANAGEMENT | | |

| | | |

|SYMPTOM MANAGEMENT | | |

| | | |

|HOME BASED CARE NURSING | | |

| | | |

|PSYCHOSOCIAL SERVICES | | |

| | | |

|VOLUNTEER SUPPORT AT HOME | | |

| | | |

|TERMINAL CARE | | |

| | | |

|ADMISSION TO IN PATIENT UNIT | | |

| | | |

|OTHER | | |

| | | |

3. MEDICAL INFORMATION

3.1 PRIMARY DIAGNOSIS:………………………………………………………………………

Morphology code……………………………………ICD 10 ...........................

3.2 DATE OF PRIMARY DIAGNOSIS:……………………………………………………………

3.3 SECONDARIES

|METASTASES |YES |DATE DIAGNOSED |

|Liver | | |

|Lung | | |

|Bone | | |

|Brain | | |

|Nodes | | |

|Other | | |

3.4 PROGNOSIS:………………………………………………………………………………………...

……………………………………………………………………………………………………………..

3.5. TREATMENT

|NATURE |YES |MORE INFORMATION AND DATE COMPLETED |

|Surgery | | |

| | | |

|Radiotherapy | | |

| | | |

| | | |

|Chemotherapy | | |

| | | |

| | | |

3.6. MEDICATION IN USE:……………………………………………………………………………

……………………………………………………………………………………………………………..

……………………………………………………………………………………………………………..

……………………………………………………………………………………………………………..

|3.7. PAST MEDICAL HISTORY: | |

| | |

|……………………………………………………………………………………………………….. | |

| | |

|……………………………………………………………………………………………………….. | |

| | |

|………………………………………………………………………………………………………. | |

4. IS THE PATIENT AWARE OF THE REFERRAL TO HOSPICE AND THEIR DIAGNOSIS?

|Yes |No |

| | |

5.REFERRING DOCTOR’S NAME (please print):…………………………………………………

REFERRING HOSPITAL (please print):……………………….……………………………………

…………………………………………………………………….Tel: ……………………………….

PLEASE ATTACH HISTOLOGY REPORT/S TO CONFIRM DIAGNOSIS

Doctor’sSignature…………………………………………………………….

DATE:…………………………………………………

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