Antenatal Home Care Program Referral Form

AHCP pager # 932-7973
AHCP fax #940-2189
Women’s:
ANTENATAL HOME CARE PROGRAM
REFERRAL FORM (Draft)
WRS5____PNAU___Other____
NAME:
D.O.B.
MHSC#:
ADDRESSOGRAPH
St. Boniface: B3____Triage___Other____
PHIN#:
Dr.
Diagnosis: HYPERTENSION PPROM TPTL Other______________
Address: ______________________________Temporary address:
Phone: _______________________________
Contact person name & phone: __________________________________
G________P________ Gestation____________ EDC_______________________
Social Supports: _____________________________________________
Hospital admission date: ____________ Discharge date: ___________________
Range of vital signs (past 24 hours):_____________________________________________
BP cuff size: Regular Large WT: __________
Condition Summary/ Significant Psychosocial and Medical Hx:
____________________________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________________
Discharge Medications: _________________________________________________________
FAU:
Date___________BPS:________Presentation___________AFV____________EFW______
Next Appointments:
FAU ______________ Dr. ____________________ Other ____________________
Include with referral form: Prenatal sheet
FAU report
Vital signs flow sheet
Latest lab results
Nursing database
Completed by:(Print)_________________(Signature):________________ Date:____________
July 26, 2009

Guidelines for Completion of the AHCP Referral Form
In early 2009 revisions to the Antenatal Home Care Program’s referral form were made in consultation with the
nursing staff at both the St. Boniface and Women’s Hospitals. The form now consists of a one page document with
the date July 26, 2009 at the bottom. The goal of the form is to provide key information to the AHCP nurses while
increasing ease of use for nurses on the busy inpatient units.
The same referral form is used by the hospital staff in the following areas: triage/PNAU, antepartum, L&D/LDRP
and FAU. The Antenatal Home Care nurses use the form to take referrals from doctor’s office and clinics via the
phone.
The following key points may assist inpatient sites in making a referral:
1. The patient referred to the program from hospital normally has the requested information on various forms, within
her hospital chart i.e. lab results, vital sign flow sheet. These forms can be faxed as is, rather than having a nurse
or unit clerk duplicate information by writing it out again on the referral form.
2. The pager and fax numbers for the AHCP are in the top left portion of the form, under the area identifying the
hospital and unit generating the referral.
Any questions, just contact the caseload coordinator. A call prior to faxing the referral is necessary to ensure there
is room on the program for your patient. Page 932-7973 and a nurse will call you back.
3. Use addressograph to avoid writing in key demographic information.
4. Check the box in front of the condition patient requires monitoring of.
5. Complete address, temporary address if applicable, and phone numbers (home and cellular) as this is vital
information to ensure that the client can be contacted and visited promptly after she leaves hospital.
6. Contact person- will be called if client is not at home address or phone number listed.
7. Gravida/ Parity/ Gestation and EDC- must be completed.
8. Hospital admission date and discharge date- a referral form may be sent on a client prior to discharge home.
The AHCP nurse will refer to the discharge date, and on that date will confirm patient has gone home and whether
any changes in condition have occurred.
9. Range of vital signs (past 24 hrs): no need to complete if sending by fax the vital signs flow sheet from patient
chart.
10. BP cuff size: indicate by checking appropriate sized cuff that was used on the patient in the hospital.
The AHCP lends each GH patient an auto BP cuff- knowing in advance the cuff size ensures the proper cuff is
brought to the visit.
11. Weight: most recent weight in kilograms, used for ongoing 24 hr urine samples to run creatinine clearance.
12. Condition summary/Significant psychosocial and medical history:
List frequency of warning signs and symptoms related to current condition, presence of any chronic illnesses,
previous pregnancy complications.
When client has received corticosteroids in hospital, note it here.
13. Discharge medications: complete name, dose and schedule for all medications client is to take when at home.
14. FAU: if report will be faxed separately, no need to complete this area.
15. Next appointments: identify dates as booked. If return appointment needs to be arranged by patient or
program nurse, write that in.
16. Include with referral form: check off the items being sent with referral form. All items listed are requested by
the program.
17. Completed by: (Print) / (Signature) of person completing the form. Used by AHCP nurses as contact for more
information when required.
18. Date: date form once completed. This referral form becomes the first portion of the patient’s home chart and
should include date information was transferred to AHCP.
Created on May 10, 2009 by Karen Daeninck, revised June 27 and July 26, 2009