Best Questions for Nursing Referrals in NDIS
A referral that says “needs nursing” can hide a very different reality: a wound that is no longer healing, a catheter routine that support workers are unsure about, recurrent urinary symptoms, or a family struggling to manage an increasingly complex bowel routine. The best questions for nursing referrals turn that uncertainty into a clear clinical picture, so the right assessment, documentation and risk response can begin without delay.
For Support Coordinators, families, discharge teams and SIL providers, good referral questions are not extra administration. They help identify whether a participant needs an assessment, clinical care plan, nursing report, support worker training, ongoing oversight, or urgent medical escalation. They also prevent a common problem: care beginning without everyone understanding the risks, responsibilities and safe daily routine.
Why nursing referrals need clinical detail
A nurse-led NDIS referral should explain more than the diagnosis. Diagnoses matter, but they do not always show how a health condition affects a person at home, what has changed, or what risks arise when care is delivered by different people across a week.
For example, “diabetes” alone does not tell a nurse whether the participant has recurrent hypoglycaemia, whether blood glucose monitoring is occurring reliably, who responds to abnormal readings, or whether support workers require clinical direction. Likewise, “continence concerns” could mean an overdue continence assessment, repeated leakage and skin breakdown, an unstable catheter routine, or a significant change in bowel function.
Clear information supports practical nursing assessments, safe dignity-focused care and reports that can explain functional impact and clinical risk in a way that is useful for NDIS planning discussions. It also helps the nurse prioritise appropriately. If there are signs of acute illness or immediate deterioration, a standard referral is not a substitute for urgent medical advice or emergency care.
12 best questions for nursing referrals
1. What is the main clinical reason for the referral?
Start with the issue that needs attention now. Be specific about whether the concern relates to wound care, pressure injury prevention, continence, stoma care, catheter support, bowel or bladder routines, medication, diabetes, skin integrity or another complex health need.
A focused reason helps determine the appropriate first appointment and whether an in-home assessment is needed. “Increasing redness around a chronic wound” gives far more direction than “requires wound support”.
2. What has changed, and when did the change begin?
A change from the participant’s usual baseline often matters as much as the condition itself. Ask whether there has been new pain, leakage, odour, redness, drainage, constipation, diarrhoea, reduced appetite, reduced mobility, altered cognition, repeated infections or an increase in hospital presentations.
Include timing where possible. A problem that developed over two days may need a different response from one that has been present for six months. This question also helps identify whether there may be a change of circumstances requiring current nursing evidence.
3. Is there an immediate clinical risk that needs escalation?
Ask directly about red flags, including rapidly worsening wounds, spreading redness, fever, uncontrolled pain, significant bleeding, acute breathing difficulty, severe dehydration, sudden confusion, absent stoma output where this is unusual for the person, or catheter issues with concerning symptoms.
The answer may mean the participant needs prompt review by their GP, treating team, urgent care service or emergency services rather than waiting for a routine nursing appointment. Safe referrals clearly separate urgent escalation from ongoing clinical support in the home.
4. What are the participant’s diagnoses, relevant history and treating team arrangements?
Provide the health history relevant to the current concern, including recent admissions, surgeries, known allergies, recurrent infections, pressure injury history and existing specialist involvement. It is also helpful to note the GP, hospital outpatient team, continence service or other clinicians already involved.
This prevents duplicated work and enables nursing care to align with existing medical instructions. It also identifies gaps, such as a participant whose wound dressings are continuing after discharge but who has no documented review plan.
5. What does the current daily routine look like, and where is it breaking down?
This is where referral information becomes genuinely useful. Describe what happens in practice: how often a dressing is changed, the catheter care routine, when bowel care occurs, who monitors blood glucose, or how pressure areas are checked and managed.
Then describe the difficulty. The issue may be missed steps, inconsistent timing, unclear instructions, unsuitable products, limited documentation, pain during care, or staff uncertainty. Nurse-led NDIS care is most effective when recommendations can work in the participant’s real home environment, not just on paper.
6. What devices, supplies or treatments are currently in use?
List relevant items such as a stoma, indwelling or suprapubic catheter, continence products, wound dressings, pressure-relieving equipment, glucose monitor or medication administration aids. Include the prescribed treatment or current product routine if known.
Photographs of wounds or skin concerns can be useful where consent has been obtained and secure processes are followed, but they should never replace a clinical assessment. Include details of any supply shortages, recurring leakage or products that are causing skin irritation.
7. What medication or diabetes support is involved?
Medication information should identify the practical task and the associated risk. Is support needed with prompting, administration, monitoring for effects, storage, documenting doses, or responding to a missed dose? For diabetes, clarify the monitoring routine, treatment plan, recent abnormal readings and whether the participant has a documented response plan.
Nursing input can help establish safe boundaries for care and identify where clearer clinical instructions or staff education are required. It should remain coordinated with the prescriber and treating medical team.
8. What is happening with skin integrity, wounds or pressure care?
Skin concerns can escalate quickly when moisture, friction, immobility, incontinence, nutrition issues or poorly fitting products are involved. State the location of the concern, how long it has been present, whether it is changing, current dressings or creams, pain levels and any known infection concerns.
For participants at risk of pressure injury, include mobility patterns, time spent in bed or seated, ability to reposition, current skin checks and whether support workers know what changes to report. This allows a nurse to build a prevention plan that is practical for everyday delivery.
9. Who is providing the care, and are they trained and confident?
Many referrals arise because care is being delivered by a mix of family members, support workers and providers, with no shared clinical direction. Identify who completes each task, whether a current care plan exists, and where confidence or competency gaps have been identified.
Support worker training and clinical oversight may be needed when workers are expected to follow a complex routine safely. The goal is not simply to hand over a set of instructions. It is to make sure people understand what to do, what to document and when to escalate.
10. What documentation already exists?
Ask for current hospital discharge summaries, GP or specialist instructions, medication charts, wound plans, continence information, behaviour of symptoms over time, incident reports and previous nursing assessments where available. Also clarify whether there is an existing clinical care plan and when it was last reviewed.
Existing records give the nurse a starting point, but they should be checked against what is happening now. A care plan that has not kept pace with a participant’s changing needs can create risk even when it appears comprehensive.
11. What does the participant want, and has consent been confirmed?
Clinical care should be led by the participant’s preferences wherever possible. Ask how they prefer personal health matters to be discussed, whether they are comfortable with an in-home assessment, which family members or decision-makers may be involved, and what outcomes matter to them.
Consent and dignity are especially relevant for continence, bowel, bladder, stoma and wound care. Clear consent arrangements also allow the nursing team to communicate appropriately with Support Coordinators, families and other clinicians.
12. What outcome is needed, and by when?
The final question keeps the referral purposeful. The requested outcome might be a continence assessment, wound review, pressure care plan, catheter or stoma care assessment, staff training, a clinical care plan, or a nursing report for a plan review or change of circumstances.
Be clear about timeframes, particularly where discharge is pending, current support arrangements are not safe, or plan review evidence is needed. A defined request enables clear reports for Support Coordinators and helps everyone understand the next clinical step.
Turning answers into a referral-ready brief
A strong referral does not need to be lengthy. It needs enough detail to show the current issue, the risks, what care is occurring, who is involved, relevant documentation and the requested outcome. If information is incomplete, say so rather than guessing. A nurse can clarify missing details during triage or assessment.
For Adelaide participants with complex health support needs, Compassion Wings can use this information to assess priorities, organise practical nursing assessments and develop care recommendations suited to home routines. Where needed, the process can also include support worker education, clinical care plans and nursing reports that explain the evidence behind recommended supports.
The most useful referral question is often the simplest: “What would make this person safer and more comfortable at home this week?” When the answer is supported by clear clinical information, the path to appropriate care becomes much easier to see.
