LAMBETH INTERMEDIATE CARE SERVICES REFERRAL FORM
FORM A
Please complete Form A then either Form B or C and fax to: 0203 049 4014 Tel: 0203 049 4004
Patient Name:
NHS No.
Title Mr / Mrs / Miss / Ms / Dr / Other
DoB
M
Drug Allergy/Significant
Adverse Reaction
F
Address
Yes
No
Unknown
Next of Kin/Other Carer/Contact Person
Relationship
Postcode
Telephone
Telephone
GP Name
Surgery
GP telephone
Hospital Name
Ward
Ward telephone
Consultant
Date admitted to hospital
Anticipated discharge/transfer Date
Presenting Complaints/Clinical Summary
Principal Diagnosis
Past Medical History/co morbidities
ABOVE INFORMATION CAN BE PROVIDED BY ATTACHING EDL IF PREFERRED
Service required
(please tick)
Bed based IC services (form B)
Home based IC services
Reason for referral (PLEASE STATE WHY BED-BASED RATHER THAN HOME BASED CARE IS REQUIRED):
COMMUNICATION
Interpreter
required
Language spoken
Hearing
problems
Vision
problems
Yes
No
Yes
No
Cognitive impairment
Other
communication
Problems e.g.
dysphasia?
Yes
No
Yes
No
Ethnicity
Please provide details
Yes
No
Please state MMSE/MTS/AMT Score
IF KNOWN PLEASE SUPPLY INFORMATION ON THE FOLLOWING – attach with referral
Behavioural/Mental Health needs/Substance abuse
Yes
No
Unknown
Social Care – new or previous care package
Yes
No
Unknown
Current safeguarding process in place
Yes
No
Unknown
NOW COMPLETE EITHER
FORM B FOR BED-BASED CARE
or
FORM C FOR HOME-BASED CARE
Form A & B or C to be sent to IC Services at time of referral – Form D to be completed on discharge
V-16 - Jan 2011
FORM B
Lambeth Community Health Intermediate Care Services
BED BASED
Complete for admission to
Patient Name
Intermediate Care
DOB
Infection control
MRSA status (details of protocols if relevant)
Positive
Negative
Not Tested
C-Diff
Positive
Negative
Not Tested
Other (please give details)
Risk Assessments at time of referral - (include date taken)
Waterlow
Date
Stratify Score
Date
Potential for
yes
no Requires 1 to 1 supervision (specialing)?
yes
no
History of falls
wandering
Tissue Viability
Pressure ulcer/s
(state site and grade)
Wound/s
(state site and grade)
Mobility (please tick Pre-Morbid (PM) and Current Level (CL) of functional ability below)
PM
Bed
Transfers
Chair
Transfers
CL
PM
CL
PM
CL
PM
yes
CL
PM CL
Independent
Supervision
Assistance of 1
Assistance of 2
Hoist
Independent
Supervision
Assistance of 1
Assistance of 2
Hoist
Mobility
Independent
Supervision
Assistance of 1
Assistance of 2
Stairs
Independent
Supervision
Assistance of 1
Assistance of 2
Weight bearing status
no
Walking aid type (please state)
Orthopaedic Guidelines (please include any guideline on Therapy goals / transfer form
PADLS (washing, dressing,
Independent
Supervision
eating, drinking)
DADLS (housework, meals,
Independent
Supervision
shopping)
Equipment - specialist equipment/guidelines needed?
Type of bed (low/falls bed))
yes
no
Type of mattress
Bariatric needs (BMI >40kg/m²)
yes
no
Therapy equipment
Oxygen
yes
no
Assistance
Assistance
yes
Wheelchair user?
no
If patient requires continuous O2 therapy please order condenser and send with patient
Nutrition
Any dietary
needs?
yes
no
Feeding regime / dietary needs / SALT / dietician advice to be sent on day of discharge
Feeding pump /
yes
no type
equipment used
Continence
Incontinent of
yes
no
Incontinent of faeces
urine
If Catheterised Catheter type
Date inserted
eg long term, size etc.
Reason for referral
Please tick
yes
no
Pads worn
Period of review in inpatient setting to prevent/delay admission to long term care
2
Nursing care (eg tissue viability, observations, end of life care etc)
3
Rehabilitation - attach REHAB GOALS/TRANSFER INFORMATION
Designation
no
Reason for
catheterisation
1
Anticipated discharge destination:
Name of person completing the form
yes
Contact details
Form A & B or C to be sent to IC Services at time of referral – Form D to be completed on discharge
Date
V-16 - Jan 2011
FORM C
Lambeth Community Health Intermediate Care Services
Complete for admission to
HOME BASED
Patient Name
1
Intermediate Care
DoB
NHS No.
Infection control
MRSA status (details of protocols if relevant)
2
Tissue Viability
Pressure ulcer/s or Wound/s
yes
no
Referral made to DN?
yes
no
Details:
3
Falls History
Falls history
yes
4
Cause of falls if known:
no
Functional Ability
Transfers
Before admission
Current level
Mobility
Previous package
of care and details
of help provided
5
6
NB: the Supported Discharge Team accepts patients with assistance of 1 or less however will accept patients requiring
assistance of 1 or more if a carer/family member/friend is able to and has agreed to assist on a consistent basis
Equipment
Specialist equipment needed? Has this been ordered for delivery?
Access/Risk Details
Does the patient live alone?
7
yes
Are there any know risks
associated with the
yes
property?
Can patient provide access to the
property?
Continence
Incontinent of urine
yes
no
no
yes
no
Are there people or pets in clients
home that could cause a risk?
no
Incontinent of
faeces
yes
no
If no, provide
access details:
yes
no
Pads worn
Date inserted
Medicines Management
Able to self administer
medication/s?
9
no
If yes, provide details:
If Catheterised, state catheter type
e.g. long term, size etc.
8
yes
Other Services Involved
yes
no
If no, provide details of
method of administration
DO NOT use this form for enablement / LIET referrals
Therapy Transfer Information MUST be sent with referral form
Name of person completing form
Designation
Contact details
Form A & B or C to be sent to IC Services at time of referral – Form D to be completed on discharge
Date
V-16 - Jan 2011
FORM D
Day of Transfer
THIS FORM MUST BE COMPLETED ON THE DAY OF TRANSFER
PLEASE FAX THIS FORM BY 09.30 ON THE DAY OF TRANSFER TO: 0203 049 4014
AND PLEASE SEND THIS FORM WITH THE RECORDS THAT ARE TRANSFERRED WITH THE PATIENT
Patient Name
DoB
Date of transfer to Intermediate Care
Observations ( to be taken on day of transfer)
Temp.
Pulse
Resp.
Wt
O2 sats
PAR Score
If diabetic blood sugar
If observations abnormal explain why you consider patient safe for transfer
MRSA protocols attached
Yes
NA
Patient discharged with appropriate equipment e.g. walking aid
Yes
NA
Dressings – one weeks supply supplied
Yes
NA
Continence supplies
Yes
NA
If continuous Oxygen required, condenser supplied
Yes
NA
Medication – correct up to date medication supplied (two weeks supply)
Yes
NA
EDL discharge summary and medication list attached
Includes Warfarin?
Yes
No
Warfarin dose on day
of transfer
Yes
Latest INR result (if applicable)
Yellow Book attached
Yes
No
NO DOSETTE BOXES FOR BED BASED INTERMEDIATE CARE
Follow up
appointment(s)
booked
Please provide details of any
Yes
No
Has transport been booked for
next follow up appointment
(particularly for dialysis clinic)
Please provide details here
Patient is medically fit for transfer
of care
Doctor to sign here to confirm
Name of clinician completing this form
Designation
Contact details
Form A & B or C to be sent to IC Services at time of referral – Form D to be completed on discharge
Date
V-16 - Jan 2011