Someone from the patient's health care team completes this one-page Yukon form (YG 6898) to refer a person for hospice in a continuing care facility, namely Wind River Hospice House at Whistle Bend Place in Whitehorse. It captures physician involvement, the palliative diagnosis, Palliative Performance Scale score and prognosis. It must accompany the Continuing Care Facility Referral form.
A member of the health care team records the referring, family and attending physicians, whether a palliative care physician is involved, the diagnosis, PPS score, prognosis, and patient and family awareness of the diagnosis and prognosis. The general Continuing Care referral covers the rest of the applicant's details.
Download the current version from the source each time; forms change without notice.
Hospice referral form
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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Yukon's page says the form is for someone from the person's health care team to fill out, and it is needed to enter hospice in a Yukon continuing care facility. It must be sent together with the Continuing Care Facility or Community Day Program Referral form.
End-of-life stays are for adults with a clearly life-limiting illness in its advanced stages and a prognosis of 3 months or less, with longer prognoses considered case by case. Respite stays need a palliative diagnosis and a prognosis of 12 months or less.