Acute Care to Rehab & Complex Continuing Care (CCC) Referral

Transcription

1 o General Rehabilitation Low Intensity Rehabilitation (GRH, SJHCG) o (CMH, GRH, SJHCG) o Chronic Assisted Ventilator (GRH only) o o Ischemic o Hemorrhagic Stroke Rehab: Program Readiness Date: Complex Medical Management (GRH, SJHCG, GMCH) If Faxed Include Number of Pages (Including Cover): Pages Estimated Date of Rehab/CCC Readiness: DD/MM/YYYY Patient Details and Demographics Health Card #: Version Code: Province Issuing Health Card: Health Card #: Version Code: Surname: Given Name(s): Known Address: Home Address: City: Postal Code: Country: Province: Telephone: Alternate Telephone: Alternate Telephone: Current Place of Residence (Complete If Different From Home Address) : Date of Birth: DD/MM/YYYY Gender: Patient Speaks/Understands English: Primary Language: English French M F Other Interpreter Required: Marital Status: Other Primary Alternate Contact Person: Relationship to Patient(Please check all applicable boxes) : Telephone: POA SDM Spouse Alternate Telephone: Secondary Alternate Contact Person: Telephone: POA SDM Spouse Alternate Telephone: N/A: Other Alternate Telephone: Program Requested: Current Location Name: Current Location Address: Province: Postal Code: Current Location Contact Number: Alternate Telephone: ne Provided: Relationship to Patient(Please check all applicable boxes) : Insurance: Other Bed Offer Contact (Name): City: Bed Offer Contact Number: Page 1 of 7 WW

2 Medical Information Primary Health Care Provider (e.g. MD or NP) Surname: Given Name(s): ne Reason for Referral: Allergies: Known Allergies Infection Control: ne --- If, List Allergies: MRSA VRE Admission Date: DD/MM/YYYY CDIFF ESBL TB Date of Injury/Event: DD/MM/YYYY Other (Specify): Surgery Date: DD/MM/YYYY Rehab Specific Patient Goals: CCC Specific Patient Goals: Nature/Type of Injury/Event: Primary Diagnosis: History of Presenting Illness/Course in Hospital: Current Active Medical Issues/Medical Services Following Patient: Past Medical History: Height: Weight: Is Patient Currently Receiving Dialysis: Peritoneal Hemodialysis Frequency/Days: Location: Is Patient Currently Receiving Chemotherapy: Duration: Location: Page 2 of 7

3 Is Patient Currently Receiving Radiation Therapy: Duration: Location: Concurrent Treatment Requirements Off-Site: Details: CCC Specific Medical Prognosis: Improve Services Consulted: PT Pending Investigations: Remain Stable OT SW Deteriorate Palliative Unknown Palliative Performance Scale: Speech and Language Pathology Nutrition Other Details: Frequency of Lab Tests: Unknown ne Respiratory Care Requirements Does the Patient Have Respiratory Care Requirements?: -- If, Skip to Next Section Supplemental Oxygen: Ventilator: Breath Stacking: Insufflation/Exsufflation: Tracheostomy: Cuffed Suctioning: C-PAP: Patient Owned: Bi-PAP: Rescue Rate: Cuffless Patient Owned: Additional Comments: IV Therapy IV in Use?: -- If, Skip to Next Section IV Therapy: Central Line: PICC Line : Swallowing and Nutrition Swallowing Deficit: Swallowing Assessment Completed: Type of Swallowing Deficit Including any Additional Details: TPN: Enteral Feeding: (If, Include Prescription With Referral) Page 3 of 7

4 Skin Condition Surgical Wounds and/or Other Wounds Ulcers: -- If, Skip to Next Section 1. Location: Stage: Dressing Type: (e.g. Negative Pressure Wound Therapy or VAC) Time to Complete Dressing: Less Than 30 Minutes Greater Than 30 Minutes 2. Location: Dressing Type: (e.g. Negative Pressure Wound Therapy or VAC) Time to Complete Dressing: Stage: Less Than 30 Minutes Greater Than 30 Minutes 3. Location: Dressing Type: (e.g. Negative Pressure Wound Therapy or VAC) Time to Complete Dressing: Stage: Less Than 30 Minutes Greater Than 30 Minutes * If additional wounds exist, add supplementary information on a separate sheet of paper. Continence Is Patient Continent?: -- If, Skip to Next Section Bladder Continent: If : Occasional Incontinence Incontinent Bowel Continent: If : Occasional Incontinence Incontinent Pain Care Requirements Does the Patient Have a Pain Management Strategy?: Controlled With Oral Analgesics: Medication Pump: Epidural: Has a Pain Plan of Care Been Started: -- If, Skip to Next Section Communication Does the Patient Have a Communication Impairment?: -- If, Skip to Next Section Communication Impairment Description: Page 4 of 7

5 Cognition Cognitive Impairment: Unable to Assess -- If, or Unable to Assess, Skip to Next Section Details on Cognitive Deficits: Has the Patient Shown the Ability to Learn and Retain Information: Delirium: -- If, Details: -- If, Cause/Details: History of Diagnosed Dementia: Behaviour Are There Behavioural Issues: -- If, Skip to Next Section Does the Patient Have a Behaviour Management Strategy?: Behaviour: Need for Constant Observation Verbal Aggression Physical Aggression Agitation Sun downing Exit-Seeking Resisting Care Other Wandering Restraints -- If, Type/Frequency Details : Level of Security: n-secure Unit Secure Unit Wander Guard One-to-one Social History Discharge Destination: Multi-Storey Bungalow Apartment LTC Retirement Home (Name): Accommodation Barriers: Smoking: Unknown Details: Alcohol and/or Drug Use: Details: Previous Community Supports: Details: Discharge Planning Post Hospitalization Addressed: Details: Discharge Plan Discussed With Patient/SDM: Page 5 of 7

6 Current Functional Status Sitting Tolerance: More Than 2 Hours Daily 1-2 Hours Daily Less Than 1 Hour Daily Has not Been Up Transfers: Supervision Assist x1 Assist x2 Mechanical Lift Ambulation: Supervision Assist x1 Assist x2 Unable Number of Metres: Weight Bearing Status: Bed Mobility: Full As Tolerated Partial Toe Touch Supervision Assist x1 n Assist x2 Activities of Daily Living Level of Function Prior to Hospital Admission (ADL & IADL) : Current Status Complete the Table Below: Activity Cueing/Set-up or Supervision Minimum Assist Moderate Assist Maximum Assist Total Care Eating: (Ability to feed self) Grooming: (Ability to wash face/hands, comb hair, brush teeth) Dressing: (Upper body) Dressing: (Lower body) Toileting: (Ability to self-toilet) Bathing: (Ability to wash self) Page 6 of 7

7 Special Equipment Needs Special Equipment Required: HALO Orthosis Bariatric -- If, Skip to Next Section Other Pleuracentesis: Need for a Specialized Mattress: Paracentesis: Negative Pressure Wound Therapy (NPWT): Rehab Specific AlphaFIM Instrument Is AlphaFIM Data Available: -- If, Skip to Next Section Has the Patient Been Observed Walking 150 Feet or More: If Raw Ratings (levels 1-7): If Raw Ratings (levels 1-7): Projected: Transfers: Bed, Chair Expression Transfers: Toilet Bowel Management Locomotion: Walk Memory Eating Expression Transfers: Toilet Bowel Management Grooming Memory FIM projected Raw Motor (13): FIM projected Cognitive (5): Help Needed: Attachments Details on Other Relevant Information That Would Assist With This Referral: Please Include With This Referral: Admission History and Physical Relevant Assessments (Behavioural, PT, OT, SLP, SW, Nursing, Physician) All relevant Diagnostic Imaging Results (CT Scan, MRI, X-Ray, US etc.) Relevant Consultation Reports (e.g. Physiotherapy, Occupational Therapy, Speech and Language Pathology and any Psychologist or Psychiatrist Consult tes if Behaviours are Present) Completed By: Contact Number: Title: Direct Unit Phone Number: Date: DD/MM/YYYY AlphaFIM and FIM are trademarks of Uniform Data System for Medical Rehabilitation (UDSMR), a division of UB Foundation Activities, Inc. All Rights Reserved. The AlphaFIM items contained herein are the property of UDSMR and are reprinted with permission. Page 7 of 7