ST. JAMES’S HOSPITAL
RESPIRATORY ASSESSMENT UNIT (RAU)
HOME VISIT REFERRAL FORM
Please tick service required
Admission Avoidance 
(inclusion/exclusion criteria apply)
The team will provide home visits to manage acute exacerbations of COPD in the community.
Long Term Oxygen Therapy/ Non-invasive ventilation (NIV) 
The team will provide a once off home visit for patients reporting difficulties following commencement of
home oxygen or NIV.
Supportive Visits 
The team will provide home visits for patients with advanced COPD or Pulmonary Fibrosis. Respiratory nursing
and physiotherapy support and advice for patient and carers is provided.
Patients name
PMHx:
Address
Telephone
Current problems:
Date of birth
SJH MRN (if
known)
Next of kin name
and contact
details
Previously
attended RAU
Current medications:
Yes
No
RAU July 2012 Page 1 of 2
ST. JAMES’S HOSPITAL
RESPIRATORY ASSESSMENT UNIT (RAU)
HOME VISIT REFERRAL FORM
Patients Name:
Address:
Date of Birth:
For ADMISSION AVOIDANCE home visits please ensure that patient meets the
following inclusion and exclusion criteria :
(1)
(2)
(3)
(4)
(5)
Patients are suitable for admission avoidance home visits if the meet all of the
following Inclusion Criteria
Confirmed diagnosis of COPD
Agreement by patient and carer / family to home visits
Suitable social circumstances for home nursing (must have access to telephone)
Appropriate degree of home support if living alone.
Resides in SJH catchment area
(1)
(2)
(3)
(4)
Patients are Not suitable for admission avoidance home visits if they meet any of
No
the following Exclusion Criteria
Suspected underlying malignancy
Suspected PE, MI, CCF
Requirement for IV therapy (unless community IV’s arranged)
Cognitive impairment that prevents self care (unless sufficient care provided by carer)
Referrer details:
Name ______________________
Telephone _________________
Address _____________________
Fax _______________________
Signature ____________________
Referral date ___________________
Procedure for Referral:






Please telephone RAU to discuss ALL referrals with a member of the team.
Complete & fax both pages of referral form to 01 4103765.
Inclusion/Exclusion criteria must be completed for admission avoidance
home visits.
Referrals for admission avoidance accepted Monday to Thursday only.
Admission avoidance referrals will be visited next day. All other referrals
will be visited within 5 working days.
Office hours Monday to Friday 08.00 to 18.00.
Tel: 01 4103763 or 4103000 bleep 325/360
FAX: 01 4103765
RAU July 2012 Page 2 of 2
Yes