THERAPY ASSESSMENT INITIAL ASSESSMENT

Transcription

1 Trusted Assessor Referral for Caterham Dene Tandridge Heights ICT THERAPY ASSESSMENT NHS Number Patient s Name.D.O.B. Hospital ESH Ward... Consultant Admission date:.. Address Tel No.... GP Practice... NOK... Heel to POP measurement: Heights sheet given ( / / ) returned PATIENT CONSENT FOR ASSESSMENT AND TREATMENT A. PATIENT CONSENT GAINED Yes No If patient unable to consent, please complete section B. The patient has received an explanation of the intervention, the benefits and risks, and alternatives, as appropriate to their needs and level of understanding. B. PATIENT UNABLE TO PROVIDE VALID CONSENT Reason: Assessment and treatment conducted in the patient s best interests. Diagnosis: INITIAL ASSESSMENT Weight-bearing status FWB PWB TWB NWB (Duration ) Precautions discussed N/A PMHx: HPC: Number of previous ED attendances in last 24 months: Patient prescribed bone strengthening Fall from own height High impact Low impact medication pre-admission: Y/N Previous falls: Y/N No of falls in last 3 months: Assessed by a Therapist Day 1 Physio/OT joint session : Y/N Subjective: Patients comments, appearance etc (Including nursing staff comments, swelling/bruising etc). SOCIAL HISTORY - Completed with Patient Family/NOK/Carer Lives in: House Bungalow Mobile Home Flat floor ( ) Residential/Nursing Home Lives: Alone With Others Pets Is a Carer Warden assisted Comments Owner: Private Council Housing Association Rented Other Level Sloping Uneven Steps Ramp Lift Key safe Key in hospital External Access: Internal Stairs: Stairs Lift Stair lift Steps Bannister (ascending) : Left Right Previous Support: Carer Frequency Agency Private/Social Care Funded Family Friends Day centre per week ( ) District Nurse per week ( ) Alarm Pullcord / Pendant Other: Lounge: Chair transfers: Independent Ax1 Ax2 Riser/Recliner Central heating Gas/Electric fire

2 Kitchen: Prepare own meals Other MOW Cooker Microwave Where meals eaten: Table/chairs P/stool Trolley ADL: Shopping: Cleaning: Laundry: Transport: Medication management: Bedroom: Upstairs Downstairs Level Bed transfers: Independent Ax1 Ax2 Bed: Single Double Bed Lever Profiling Height adjustable Y/N Bathroom: Personal Care: Upstairs Downstairs Level Bath Bath seat / board Bath lift Shower over bath Step-in shower Walk-in shower with seat? Y/N Bath/Shower rails Usual washing method: Shower Bath Strip Wash Chair/Perching stool in bathroom? Y/N Washing: Independent Ax1 Ax2 Dressing: Independent Ax1 Ax2 Toilet: Upstairs Downstairs Level Independent Ax1 Ax2 Mowbray FSTF Rails L/R RTS 2 /4 Commode location Incontinence: Urinary Y/N Bowel Y/N Manages pads? Y/N Other information: Vision: Skin Integrity: Communication: Hand Dominance: R L Cognition: Hearing: Hearing aids worn R L Mobility / Indoors Lying sit on edge of bed Transfers Outdoors Edge of bed lying.. Exercise Tolerance: Good / Poor On/off bed Distance:.metres On/off chair Uses stairs Y/N On/off toilet Single level living? Upstairs/Downstairs Any issues or concerns raised by patient /NOK / carers: Height:

3 THERAPY DISCHARGE REPORT CURRENT ABILITY Mobility and Transfers: Indoors Lying sit on edge of bed Outdoors Edge of bed lying Exercise Tolerance: Good / Poor On/off bed Distance:.meters On/off toilet Uses stairs? Y/N On/off chair Single level living? Upstairs/Downstairs Ability on stairs Height: Personal Care: Bath Shower Strip Wash Independent Ax1 Ax2 DADL: Cooking: : Shopping: Cleaning: Laundry: Kitchen Activities: Independent Ax1 Ax2 N/A Meals to be eaten in Equipment Issued: Other Information: Splint/Brace/Sling insitu? Y/N (Duration ) Community team informed of key safe number (if required) REHABILITATION GOALS D/C to Home with/without Rehab/POC Rehab bed Placement Date discharged from ESH Signature: Name: OT/PT/TI Date: Signature: Name: OT/PT/TI Date:

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5 NURSING ASSESSMENT Please attach copy of latest blood results Skin: Pressure areas intact? type of mattress used: Braden score Wound care including date of suture or clip removal Please mark wounds and bruises Nutrition: Referral to TVN needed? Appetite Special diet MUST score Seen by dietician? Seen by SALT? Elimination: Last time bowels open Continent Incontinent Stoma Catheter Type Bowels Bladder Bowels Bladder Date inserted TWOC Has patient been exposed to or had diarrhoea and vomiting? If so please indicate bowel history for last week (based on Bristol Stool Scale) below & specify likely cause (e.g. existing bowel condition / constipation with overflow) Infection risk: eg MRSA, C.Diff, including colonisation site, date protocol completed Signature: Name: Date:

6 Cognition: Short term memory loss? Diagnosis of dementia? AMTS & date Day/night behaviour Pain and management: Observations: Temp Pulse BP RR O2 sats EWS Medications: (or copy of discharge summary with meds list) Drug Dose Frequency Allergies: Preadmission: Independent with medication? Y/N Blister Packs? Y/N Clexane prescribed? Y/N Potential to be independent with own clexane administration? Y/N (Please include prescription chart if discharged to home address) Discharge checklist: To go with patient on discharge: Discharge summary 2 weeks TTOs Notes (CDH) Drug chart (CDH) MAR chart (TH) Mobility aids (TH) Follow up outpatient appointments Next of kin contacted (patient will need clothes/shoes) Signature: Name: Date: Time:

7 Patient name: DOB: NHS number: CONSENT AND INFORMATION SHARING Information given during this assessment may be shared with others involved with your care. This will help them to understand your needs and avoid having to repeat some parts of the assessment Are there individuals or agencies with whom you do not wish information to be shared? Yes No Do you wish us to involve your family in your discharge planning? Do you consent to the information recorded during your assessment being shared with others involved in your care? If no, please provide details: Your signature: Yes Yes Date: No No Person being assessed able to give consent? Yes No If no, please provide details: Signature of Assessor: Date: IN-PATIENT CONSENT FORM TANDRIDGE HEIGHTS 1. My admission is for a period of a minimum of 48 hours to a maximum of two weeks: the length of stay will be determined by the Rapid Response Service. I understand this is NOT an admission or assessment for long term care but for a period of rehabilitation. If I choose to stay beyond the date given below, I must make financial arrangements independently with the Home Manager. 2. This admission will be no longer than two weeks and will end on DD/MM/YY. It is paid for by the NHS. 3. I understand that I am responsible for paying for any telephone calls I make, use of the hairdressing service and/or any newspapers I order during my stay. These items will be billed by the Nursing Home and the account settled by myself before discharge. I understand that there are no laundry facilities available there. CATERHAM DENE HOSPITAL 1. My admission to Caterham Dene Hospital will be for a period of rehabilitation funded by the NHS. 2. The admission will be for up to three weeks and your progress will be discussed with you by the team at Caterham Dene Hospital. I consent to go to Tandridge Heights/Caterham Dene for rehabilitation and have read and understood the conditions of my stay. Signed (patient) Date Signed (employee) Date