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Home Enteral Feeding Tube Feed In Situ

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Email Address

Reference Number

Verification Code (Please enter the code emailed to you)

Please complete this form, as fully as possible, with relevant information and details to support the referral.

Referrer's Information

*Legal First name

*Legal Last Name

*Role

Trust

*Department

*Email

*Address

*Contact Number

*Is this referral for yourself?

Key information about the Patient

*Legal First Name

*Legal Last Name

*Date of Birth

*Address

*Contact Number

*NHS number

*Registered GP practice

*Is an interpreter required?

Interpreter language Type

Consent

Consent must be sought to share personal information with Northamptonshire Healthcare NHS Foundation Trust and other organisations that can offer support relevant to this referral

*Tick this box to confirm that consent has been discussed and received

Medical

*Present and Past Medical History

*Medications

*Food Allergies / Intolerance

Food Allergies / Intolerances please provide details

*Weight in kg

*Date at which the weight was measured

*Height in metres

*Body Mass Index (BMI)

Weight history/Subjective Comments/% Weight Loss

Pressure Sore (Grade and location, Healing)

*Diabetes

Management of diabetes

Communication needs

Social

*Housebound

Support Requirements (main carer, care agency)

Safeguarding Concerns

Supporting Information for Referral

*Transfer Date

Discharge Address

Discharge Phone Number

Discharge GP Details

*GP Practice Name

GP Address including postcode

GP Phone Number

Person responsible for feeding

*Name (Carer/Family Member/ Friend)

*Relationship to patient

*Phone number

Estimated nutritional requirements per 24hr

Energy (kcal)

Fluid (ml)

Protein (g)

Na+ (mmol)

K+ (mmol)

Tube Information

*Tube Type

Other

Comments

*Manufacturer/Brand

*Size (French gauge/ length cm)

Volume of water in balloon

Any issues with insertion/Clotting issues

*Date of tube insertion if known

Swallow Recommendations

*Nil by mouth

Food Consistency, IDDSI if known / Oral intake per day

Fluid Consistency, IDDSI if known / Oral fluid intake per day

Tube Feed Regimen

*Name and pack size of feed(s)

*Total volume (ml)

*Pump rate (specify n/a if not applicable)

*Number and volume of bolus feeds (specify n/a if not applicable)

*Timing(s) of feeds

Details of water flushes (pre & post feeds/extra flushes/medications/water administration via pump) and timings

Risk of refeeding syndrome, and actions taken(Present and Past)

Details of any tolerance issues with tube feeding, and actions taken

*Pump given

If Pump is given, pump type and serial number

Is training required? (please state what training and who for)

Ancillaries provided on discharge

Syringes (state type/size)

Giving sets

Reservoir (state size)

Pump stand or backpack (state)

Adaptors (state type)

Spare tube (state type and size)

Extension set (state type)

Other (state)

*Please confirm patient will be transferred with a full 14 days supply of tube feed and equipment

Other Information

*Dietetic follow up arrangements requested

Hand over to Northamptonshire HEF team, no dietetic follow up at discharging unit

Follow up at discharging unit and I confirm I have advised GP of patient recommended nutrition prescription and attached a copy of letter to this referral (Northamptonshire HEF team will coordinate ancillaries and deliveries as per your guidance but will not provide dietetic follow up)

Shared care. I confirm I have discussed this with Northamptonshire HEF team and agreed a management plan

*Please confirm patient and/or carer has given consent for their personal information to be given to Abbott Hospital to Home, and held on their database to be used solely for the purpose of arranging deliveries of tube feed and equipment, and to enable them to access support from the Abbott Nurse Advisor

Any other relevant information for the referral

Attachments

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