Continuing Care Reasons for Referral Checklist
To facilitate consistent communication, here is a sample checklist that can be sent with the official Continuing Care referral form. Note that this checklist is NOT an official referral form.
This patient has end-stage kidney disease and has chosen Conservative Kidney Management (CKM) including NO dialysis.
Reason(s) for referral (check all that apply):
Goals of Care Designation form signed and in the client's home (y/n)? ___________ Date: ___________
Symptoms (check all that apply):
Patient's general condition:
Family Doctor or Primary Healthcare Provider
Name: ______________________ Date: ___________