London specialist inpatient rehabilitation referral form
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Frank Cooksey Rehabilitation Unit (FCRU), Orpington Hospital
Email: kch-tr.FCRUreferrals@ Tel: 01689 866380
London specialist inpatient rehabilitation referral & assessment form
|1. Patient information |
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|Patient’s name: ………………………………… Date of birth: ……… Age: …….. Gender: ……… |
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|NHS no.: ………………………………………... Name of the Primary Care Trust |
|responsible for the patient’s care: ……………………… |
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|Home address: ………………………………… Tel: ………………… |
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|………………………………… Post code: ………… |
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|Patient’s present whereabouts: |
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|An inpatient on ………………… Ward at …………………..Hospital Tel: ……………….. Fax ………………. |
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|Address of hospital …………………………………………… |
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|……………………………………………. |
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|At home at the above address |
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|Other (please specify) ……………………………………….. |
|2. Consultant/Referrer information |3. General Practitioner details |
| | |
| |Name: ………………………………… |
|Name: ………………………………… | |
| |Address: ……………………………… |
|Address: ……………………………… | |
| |………………………………. |
|………………………………. | |
| |Tel: ………………………………….. |
|Tel: ……………………………………. | |
| |…………………………………… |
|Fax: …………………………………… | |
| |Fax: …………………………………. |
4. Referring Medical Practitioner/Consultant
If, following a period of rehabilitation at the specialist neurological rehabilitation units, this patient is unable for any medical or social reasons to return home/into a suitable placement:
I agree to readmit him to this hospital/ to a bed at ………………………………… (delete as appropriate)
Signature ……………………………………………. Title ………………………………………………….
Name (please print) ………………………………… Date …………………………………………………
Ethnic Origin: Please indicate to which ethnic group your patient belongs:
|ASIAN |ANY OTHER BACKGROUND | |
|ASIAN |BANGLADESHI | |
|ASIAN |INDIAN | |
|ASIAN |PAKISTANI | |
|BLACK |AFRICAN | |
|BLACK |ANY OTHER BACKGROUND | |
|BLACK |CARIBBEAN | |
|MIXED |ANY OTHER BACKGROUND | |
|MIXED |WHITE & ASIAN | |
|MIXED |WHITE & BLACK AFRICAN | |
|MIXED |WHITE & BLACK CARIBBEAN | |
|OTHER |ANY OTHER | |
|OTHER |CHINESE | |
|WHITE |ANY OTHER BACKGROUND | |
|WHITE |BRITISH | |
|WHITE |IRISH | |
| |
|WHY WE RECORD PATIENTS’ ETHNIC ORIGIN: |
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|We serve a multi-ethnic and multi-cultural population. The recording of patients’ ethnic group is necessary for the following reasons: |
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|To identify who is currently using our services and whether those services are accessible to people from different ethnic groups. |
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|To check whether any particular groups are over or under-represented within any part of the service. |
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|To help identify patterns of illness and need amongst different ethnic groups. |
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|To stimulate and guide staff awareness of and response to the varied customs, beliefs and needs of different ethnic groups. |
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|WHO HAS ACCESS TO THIS INFORMATION: |
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|Information on an individual’s ethnic group is STRICTLY CONFIDENTIAL, as are all other patient details. |
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|Access to all patient information will be restricted to staff involved in the patient’s direct care. |
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5. Diagnosis
Primary diagnosis: ……………………………………………………………Date of onset: …………………......
Date of surgery (if applicable): ………………………………………………………………………………………
Surgical procedure: …………………………………………………………………………………………………...
Secondary diagnoses: ………………………………………………………………………………………………..
………………………………………………………………………………………………..
6. Reasons for referral
Intensive inpatient multidisciplinary rehabilitation
Disability management:
Advice for appropriate placement:
Other:
If other, please specify .………………………………………………………………………………………….....
…………………………………………………………………………………………………………………………..
7. Summary of medical/surgical history
Drug/alcohol use: ……………………………………………………………………………………………………..
History of deliberate self harm: ……………………………………………………………………………………...
Previous physical & cognitive function …………………………………………………………………………..
…………………………………………………………………………..
8. Investigations
Yes No If yes, Date Comments/Further details
CT scan: ……………….
MRI: ……………….
Other: ……………….
If the patient has had a stroke, please complete the following:
Yes No If yes, Date Comments/Further details
Echocardiogram: ……………….
Carotid doppler/duplex: ……………….
ESR: ……………….
Auto-antibody screen: ……………….
Other: ……………….
9. Current medication
1. ……………………………………………………… 4. …………………………………………………………….
2. ……………………………………………………... 5. …………………………………………………………….
3. ……………………………………………………… 6. …………………………………………………………….
10. Any additional medical/surgical information
11. Summary of disabilities
Yes No Comments/Further details
Altered state of awareness:
Cognitive/communicative problems:
Behavioural problems:
Physical deficits:
Higher respiratory needs:
12. Mobility and transfers
Transfers (Tick 1) Mobility
Independent Walking Wheelchair
Assistance from 1 Independent N/A
Assistance from 2 Supervision/help from 1 Pushed in a wheelchair
Hoist Supervision/help from 2 Independent
Bedbound Has own chair Yes/No
If yes, is it suitable Yes/No
Risk of falls Yes No
13. Vision and hearing
Yes No Comments/Further details
Visual problems:
Hearing problems:
14. Cognition and communication
Level of communication (please circle as appropriate)
Consistent yes/no responses Single word level Sentences Full phrases
Yes No Comments/Further details
Cognitive problems:
Perceptual problems:
Ability to learn:
Other:
Dysphasia:
Expressive dysphasia:
Receptive dysphasia:
Dysarthria:
Other:
Capacity to consent: …………………………………………………………………………..
If no, Has Deprivation of Liberty Safeguards been undertaken including involvement of Independent Mental Capacity Advocate?............................................................................................................................
15. Behavioural problems
Yes No Comments/Further details
Agitation:
Wandering/absconding:
Self harm:
Verbal aggression:
Physical aggression:
One to one supervision:
Yes No
Is the patient under a mental health act detention order?
Comments/Further details
16. Any additional information on patient’s current level of disabilities
17. Nursing information
Yes No Comments:
Dysphagia:
Oral feeding:
Nasogastric feeding:
PEG feeding:
Pressure sores:
Special mattress:
Other special
nursing requirements:
Urinary incontinence: If yes, occasional regular
Urinary catheter:
Faecal incontinence: If yes, occasional regular
MRSA: If yes, colonisation infection
C difficile
Tracheostomy: If yes, cuffed uncuffed
weaning programme stabilised
18. Social situation
Occupation: ……………………………………. Marital status: ……..
Next of kin information: ………………………………………. Contact details …………………………………...
Other contact information (Optional) ……………………….. Contact details …………………………………...
Relative or professional involved in patient’s care
Comments/Further details
Lives alone
Lives with:
Parents
Husband/wife/partner
Other Please specify: ………………………………………………………………….
19. Type of residence and accessibility
Comments/Further details
Owner/occupied:
Council/housing association:
No fixed abode:
Other: Please specify: ………………………………………………………..
20. Current rehabilitation input
Yes No Comments:
Physiotherapy:
Occupational Therapy:
Speech & Language Therapy:
Psychology:
Dietetics:
Social Worker:
Please attach reports from the therapists currently involved in the care of the patient, or arrange for them to be sent.
21. Goals for rehabilitation
Yes No
Primarily cognitive/communicative and behavioural
Primarily complex physical
Additional comments:
22. This referral is for consideration of the following service(s)
1. Blackheath Brain Injury Rehabilitation Centre 6. Regional Neurological Rehabilitation Unit
1.1. The Thames Brain Injury Rehabilitation Unit Homerton Hospital
1.2. The Heathside Neurodisability Unit
2. Edgware Brain Injury Rehabilitation Unit 7. Regional Rehabilitation Unit Northwick Park Hospital
3. Frank Cooksey Rehabilitation Unit 8. Royal Hospital for Neurodisability
King’s College Hospital Putney
4. Lishman Brain Injury Unit 9. Wolfson Neuro-rehabilitation Centre
Maudsley Hospital
5. Neuro-rehabilitation Unit, National Hospital
for Neurology & Neurosurgery
Reasons for choosing the service(s)
Particular specialist expertise:
Family preference:
Other:
If other, please specify …………………………….
Additional comments
This section is to be filled in by the assessor(s)
This assessment was undertaken by ………………………………………………………………………………
from the ……………………………………………………………………………….. specialist rehabilitation unit
Unidisciplinary assessment Multidisciplinary assessment
Assessment undertaken at the
Referring hospital/unit Specialist rehabilitation unit
Home Other
If other, please indicate …………………………...
Date of assessment: ………………………………….
Summary and recommendations
Suitable for the following units 1 …………………………………..
2 …………………………………..
3 …………………………………..
The patient is suitable for specialist inpatient rehabilitation Yes No
If yes, this patient is for
Primarily complex physical rehabilitation programme
Cognitive/communicative and/or behavioural rehabilitation programme
If no, please give the reasons and alternative recommendations:
Patient fit for transfer for rehabilitation Yes No
Patient requires reassessment Yes No
If yes, reasons for re-assessment
Signature ……………………………………………. Title ………………………………………………….
Name of the assessor (please print) …………………… Date …………………………………………………
Contact telephone no. (mobile) ……………………………………………………………………………………...
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