WCPR Referral Form Samples
Referral Form Using SBAR
An effective referral form can include patient information in the form of the SBAR communication technique. SBAR stands for situation, background, assessment and recommendation. Patient information under each category is shared using brief bullet points that provide enough relevant information to communicate the context and palliative needs. Open-ended fields allow referring clinicians to include details unique to their patient or the case.
S = Situation (a concise statement of the problem – what is the issue or concern)
B = Background (pertinent and brief information related to the situation – details on the patient and caregiver)
A = Assessment (analysis and considerations of options — what you found/think)
R = Recommendation (action requested/recommended — what you want to happen next)
Referral Form Using a Consultation Request
This sample form asks clinicians to select from fixed reasons for consultation, with one open-ended question as the focus of the consultation. This approach allows for consistency across multiple requests, which can help with prioritizing cases.
Referrals depend upon the patient’s unique status and needs and the clinician’s concerns.
WCPR focus on addressing the palliative needs of patients and their families. Know the criteria for referring your patient to WCPR.
This information is critical to ensuring the discussion at the WCPR will meet your patient’s needs.
Knowing the focus or aim of your WCPR will help keep the conversation as efficient as possible.
Follow-up communication with the patient’s most responsible provider is critical.