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Service Directory 2016Referral Forms
Page 1 of 77
IntroductionThe following folder includes all paper copies of the referral forms as referred to in the Service Directory. If you have any difficulties completing the forms or require additional support and advice please contact the service provider (contact details can be found in the Service Directory).
We hope these forms are helpful and will enable you to complete the referral process quickly and efficiently in order to provide the best possible care for your residents.
Useful Websites
Bristol Clinical Commissioning Group www.bristolccg.nhs.uk
Bristol Community Health http://briscomhealth.org.uk
Bristol City Council http://www.bristol.gov.uk
Personal Dementia Support for Bristol People http://www.bristoldementiawellbeing.org
St Peters Hospice http://www.stpetershospice.org.uk
Well Aware
A signposting and information service for health and wellbeing organisations and events http://www.wellaware.org.uk
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Contents
Bowel and Bladder Care Service - Continence Assessment Form...............................................4
Community Dental Service – Special Care Referral Form............................................................8
Community Respiratory Service - Bristol Community Pulmonary Rehabilitation Referral Form. 13
Community Therapy (Including Occupational Therapy and Physiotherapy) Referral Form........15
Continuing Healthcare (CHC) - Fast Track Tool Referrals Form and Equality Monitoring Form.17
Continuing Healthcare and NHS Funded Nursing Care – Application for Consideration of
Eligibility Consent Form and Multi-Professional Assessment Form - CM7.................................24
Dementia Wellbeing Service Referral Form (Care Homes with Nursing)..................................36
Dermatology Referral Form ........................................................................................................37
Deprivation of Liberty Safeguarding Referral Form.....................................................................40
Diabetes and Nutrition Services Referral Forms A & B and Equality Monitoring Form...............43
Falls Specialist Nurse (BCH) - Multi Factorial Falls Risk Assessment Tool Form.......................52
Palliative Care Services - Bristol Care Coordination Centre (Coordinating end of life care).......55
Palliative Care Patient Referral Form - St Peters Hospice..........................................................59
Parkinson’s Nurse Specialist Referral Form................................................................................63
Podiatry Clinic Referral Form......................................................................................................66
Speech and Language Therapy Service Referral Form (Adult)..................................................70
Wound Care Service Referral Form............................................................................................72
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Bowel and Bladder Care Service - Continence Assessment Form
Bristol Community HealthBladder and Bowel Service Assessment Form
Client registered as (please tick): Residential Nursing
Admission Date:
Date of Assessment:
Patient’s Name: Date of Birth:
NHS Number: Male/ Female
Address (Please include Unit or Floor): GP Surgery
Post Code: Post Code
Telephone Number: GP Telephone Number
All please complete section 1- 8
1. Presenting Bladder / Bowel Problem Action
Urinary Yes No If referrals made to Urology/
Gastroendology etc. include letters and
investigations.
If bladder problems complete a 4 day bladder diary and symptom profile
Faecal Yes No
Nocturia/ Nocturnal Polyuria
Yes No
Date of onset of problem
Who else have they consulted re this problem:
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Name ……………………….NHS number…………………………………. Date of Birth……………
3. Patient’s and/or Carer’s Aims and Goals forTreatment
If pads required please state type & size. Include hip & waist measurements to ensure correct fitting product.
4. Current Management: Please give brief details:
Toileting Regime Yes No
Pads Yes No
Sheath Yes No
ISC Yes No
Indwelling Catheter Yes No Urethral or Supra-pubic
Other
5. Relevant Health History Action
Number of pregnancies: Add details as relevant to the assessment:
Difficult deliveries Yes NoConstipation Yes No
Back Problems Yes No
Parkinson’s Yes NoMS Yes No
Hysterectomy Yes No
Dementia Yes NoSpinal Injury Yes No
Previous repair surgery Yes No
Depression Yes NoPsychiatric history Yes No
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be arranged A ‘one off’ delivery can
possible.
as soon as assessment
made to deal with your
Every effort will be
what products are required. If the patient is palliative please give details, and indicate clearly 2
Cystoscopy Yes No
Diabetes Yes NoProstatectomy Yes No
Learning disability Yes No
Weight
Other
Name ……………………….NHS number…………………………………. Date of Birth……………
6. Current Medication Action
Consider referral for medication review by GP or Pharmacist OR add MARS sheet
7. Bowel Habit Action
Daily Yes No If bowel problems complete 14 day food, stool and medication diaryAlternate days Yes No
Less often Yes No
Faecal incontinence Yes No Please refer to the Bristol Stool Chart
Does resident have awareness of the need to open bowels?
Yes No
Consistency of stool:
8. Contributory Factors ActionMemory impaired Yes No
Change in behaviour observed?
If yes how many carers?
Awareness of needing to pass urine
Yes No
Independently mobile to the toilet
Yes No
Mobile with carer Yes No
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Mobile with aid Yes No State Aid used:
Mobile with aid and carer Yes No
Please state any adaptions usedAbility to hold a utensil and drink unaided
Yes No
Can manage clothes quickly Yes No Consider Velcro on clothing
Name ……………………….NHS number…………………………………. Date of Birth……………
SECTION 9 & 10 TO BE COMPLETED BY NURSING HOMES ONLY AND MUST BE SIGNED BY A REGISTERED NURSE (or if a Healthcare Assistant completes the form then a Registered Nurse MUST countersign)
9. Urinalysis ActionResults If leucocytes/ nitrites
present or symptoms of UTI, send a clean catch specimen (CSC). Suspend assessmentuntil treatment is complete.
NitritesKetonesBloodProteinPhGlucoseSpecific gravityDysuria 10. Physical Examination ActionVerbal Consent Yes No Observe for Atrophic
vaginitis (vulval area can be red and sore, or pale dry and sore). Refer to GP for oestrogen therapy.
Penile Observation Yes NoVulval Observation Yes NoSkin Condition Satisfactory Yes No
Other comments
Signature of Assessor: ………………………………… Registered Nurse Yes No Print Name: …………………………………........ Date: ………………………………
Community Dental Service – Special Care Referral Form
BRISTOL DENTAL HOSPITAL – REFERRAL FORMSPECIAL CARE DENTISTRY
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Head and Neck Suspected Cancer referrals must be submitted via the Fast Track Office, either via Choose & Book (preferred method) or via fax on 0117 342 3266
http://www.uhbristol.nhs.uk/media/2281249/2ww_bnssg_head_and_neck_referral_2014_-_blank.pdfPATIENT DETAILS
Surname: …………………………………….……………… First name: ……………………..……………… Date of Birth: ………………….………
SECTION 1 - REFERRAL INFORMATION
URGENT ☐ ROUTINE ☐ SUITABLE FOR STUDENT TREATMENT ☐ (please tick)If recommended for student treatment, please ensure patient is aware of potential wait for treatment.
Is this referral for: A) Specialist Opinion Only? ☐ OR B) Specialist Opinion and Treatment? ☐ (please tick)
RADIOGRAPHIs a diagnostically acceptable RADIOGRAPH included with this referral?
YES ☐ NO ☐ Reason if not……..…………………………………………….
CLINICAL REASON FOR REFERRAL. Please detail reason for referral and what you want us to do for your patient.
PROVISIONAL DIAGNOSIS AND CURRENT TREATMENT PLAN IN ASSOCIATION WITH THIS REFERRAL. Please detail.
RELEVANT PREVIOUS TREATMENT HISTORY. Please detail.
SECTION 2 - ADDITIONAL INFORMATIONMEDICAL HISTORY - Please include significant hospitalisation, operations, ongoing treatment and smoking/drinking history as needed. YES ☐, please detail. NONE ☐
MEDICATION - Please state type and dosage details. YES ☐, please detail.
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NONE ☐
ALLERGIES - Please state allergy and description of reaction, if known. YES ☐, please detail. NONE ☐
OTHER INFORMATION (E.g. Living arrangements, Legal guardian)
SECTION 3 – FULL PATIENT DETAILS SECTION 4 – PATIENT PARENT/GUARDIAN, SCHOOL NURSE OR CARER DETAILS (if applicable)
Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Dr ☐ Other ☐Male ☐ Female ☐ NHS Number:
Surname:
First name:
Date of Birth:
Address:
Town/City:
Postcode:
Telephone Number:
Work Number:
Mobile Number:
E-mail Address:
Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Dr ☐ Other ☐Relationship to patient:
Surname:First name:
Date of Birth:Address:
Town/City:
Postcode:Telephone Number:
Work Number:Mobile Number:
E-mail Address:
SECTION 5 - REFERRER DETAILS SECTION 6 - PATIENT GP DETAILS (if not the referrer)Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Dr ☐ Other ☐Surname:
First name:
Job Title:
GDC/GMC Number:
Practice Name:
Mr ☐ Mrs ☐ Miss ☐ Ms ☐ Dr ☐ Other ☐Surname:First name:
Practice Name:Practice Address:
Town/City:
Postcode:Telephone Number:
E-mail Address:
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Practice Address:
Town/City:
Postcode:
Telephone Number:
E-mail Address:
SECTION 7 - COMMUNICATION & SPECIAL REQUIREMENTSDoes the patient communicate in a language or mode other than English? YES ☐, please detail. NO ☐Is an interpreter required? YES ☐, please detail. NO ☐Does the patient have any special requirements? YES ☐, please detail. NO ☐
SECTION 8 - PATIENT CONSENT TO REFERRAL AND ASSOCIATED TREATMENTHas the patient understood and consented to the referral? YES ☐ NO ☐
SECTION 9 – CONFIRMATION AND SIGNATURE OF REFERRING PRACTITIONERI confirm that this patient referral meets the current referral guidelines as issued by the Bristol Dental Hospital. (Referral guidelines are available on the BDH website). I understand that incomplete and/or inappropriate referrals will be returned for revision and may delay patient treatment. Please tick to confirm. ☐
Print Full Name:………………………………………………………………………………………………… Date:………………………….................
Signature: ………………………………………………………………………………
Please return fully completed forms to: Patient Access Team, Bristol Dental Hospital, Chapter House, Lower Maudlin Street, Bristol, BS1 2LY. Fax: 0117 342 4994. Call Centre Tel: 0117 342 4422.
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SECTION 10 - SPECIALITY SPECIFIC INFORMATION – PRIMARY CARE DENTAL SERVICE – SPECIAL CAREPATIENT DETAILS – Please enter patient identifier at top of each page.
Surname: …………………………………….……………… First name: ……………………..……………… Date of Birth: ………………….………
Surgery Visit ☐ OR Domiciliary Visit ☐Please note: Only those who are house bound who are totally unable to leave their home are seen on a domiciliary basis.Special care needs:
Social history:
Exempt from charges: NO ☐ YES ☐ Benefit:…………………………… (Please attach copy of qualifying exemption certificate)NHS dental charges will be applied unless proof of exemption is provided.NB: If you are in receipt of the following you are not exempt: ●Aged over 65, ●Disability living allowance, ●Incapacity benefit including, income based.Sensory impairment: Hearing ☐ Vision ☐ Communication ☐
Mobility:Can manage stairs ☐ Can walk with
frame☐ Can weight bear ☐
Wheelchair ☐ Bed-bound ☐ Hoisting required ☐Details:
Are you currently under the care of a doctor or having hospital treatment for any condition?
YES ☐ NO ☐
Are you/could you be pregnant? Due date? YES ☐ NO ☐Do you have/have you ever had any of the following:
CVS HEART DISEASE (e.g. angina, heart attack, heart murmurs, valve problems, heart surgery)?
YES ☐ NO ☐
Rheumatic fever, Endocarditis? YES ☐ NO ☐High blood pressure, Stroke? YES ☐ NO ☐Bleeding disorder, Taking anticoagulants, anaemia? YES ☐ NO ☐
RS ASTHMA, Bronchitis, TB other chest disease? YES ☐ NO ☐Smoker (past/present) – how many per day? YES ☐ NO ☐
GI HEPATITIS, jaundice, other liver disease? YES ☐ NO ☐GU KIDNEY, urinary tract or sexually transmitted
disease?YES ☐ NO ☐
CNS EPILEPSY, convulsions, neurological disease? YES ☐ NO ☐Learning difficulties? YES ☐ NO ☐Mental illness/ Psychiatric problems? YES ☐ NO ☐Alcohol or Drug addiction (past/present)? YES ☐ NO ☐
END DIABETES, thyroid, other hormone disorders? YES ☐ NO ☐LM Bone or joint disease? YES ☐ NO ☐
Skin disease e.g. Eczema, dermatitis? YES ☐ NO ☐ALLERGIES (E.g. penicillin, aspirin, paracetamol, latex, YES ☐ NO ☐
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Elastoplast)?Any other diseases or conditions? YES ☐ NO ☐Previous operations? YES ☐ NO ☐Previous serious illness or admissions to hospital? YES ☐ NO ☐
Signed by patient/parent/carer: Date:
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Community Respiratory Service - Bristol Community Pulmonary Rehabilitation Referral Form
Amelia Nutt Clinic, Queens Road, Withywood, Bristol BS13 8QA
FAX: 0117 987 8432
Patient Details (please print) NHS No _________________________________
Surname __________________________________________ Tel No: H ___________________
Forename _________________________________________ W _____________________
Address __________________________________________ M_____________________
__________________________________________________
Post Code _________________________________________ Communication needs ____________
DOB _________________________________________ M/F
Transport Required. No / Yes
Is there any possible risk to staff seeing this patient in clinic/at home? _____
Clinical Details
Diagnosis:
Recent discharge from hospital? Yes/ No. Date: No. of episodes in last 12 months?
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Nam
e:
NH
S N
umber
MRC Degree of breathlessness related to activities : Please tick
1 Not troubled by breathlessness except on strenuous exercise
2 Short of breath when hurrying or walking up a slight hill
3Walks slower than contemporaries on level ground because of breathlessness,
or has to stop for breath when walking at own pace
4 Stops for breath after walking about 100m or after a few minutes on level ground
5 Too breathless to leave the house, or breathless when dressing or undressing
FOR INFORMATION: Criteria for Pulmonary Rehabilitation Programme:
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INCLUSION CRITERIA EXCLUSION CRITERIA
Symptomatic shortness of breath Unstable cardiac conditions
Chronic respiratory disease Severe cognitive deficit
Motivated Metastatic cancer or renal failure
Immobile
Referral Details (please print)
Name ____________________ Signature____________________ Designation_________________
GP Name ___________________________ Consultant ____________________________
GP Address & Tel No ______________________________________________ Date ___________
Community Therapy (Including Occupational Therapy and Physiotherapy) Referral FormTo facilitate prioritisation and processing of this referral please complete every section fully.
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Complex Elderly Team Physiotherapy and Occupational Therapy Referral Form Guidelines
Please list your request under the following headings:
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Personal Details (please print)
NHS Number:
Surname: Title:
Forename(s):
Date of Birth: Sex M/F
Address:
Postcode:
Tel No:
Referral Details (please print)
Referrer’s Name:
Designation:
Contact Address:
Tel No:
Consultant:GP :GP Practice:GP telephone number:
Date of Referral:
First Language: Communication or Cultural needs:
Risk factors, must be completed.
Lives alone Y/N Main carer of another Y/N
Recent marked deterioration in abilities Y/N Community services expressing concern Y/N
Recent hospital discharge Y/N
Please provide details of current problem, related medical intervention and results of diagnostic tests:
Please state reason for referral and treatment goals:
Has the patient agreed to participate in treatment: Yes/No
Please indicate which professional is required: Physio □ OT □
Referrals made to other agencies and NHS services involved: Risks:
Send to: Community Therapy Service – Complex Elderly Team Tel: 0117 9190290Knowle Clinic Fax: 0117 9190296Broadfield Road, Bristol, BS4 2UH
OR E-MAIL : [email protected]
Date received: Prioritised by: Classification: Diagnosis code:
1. Assessment and Advice on Activities of Daily Living, e.g. Dressing, Washing/Bathing, Toileting, Cooking/Household Chores, Transfers, Mobility /Stairs, Leisure, Employment
2. Wheelchair Assessment - for patients privately purchasing a wheelchair.
3. Posture and Seating
4. Pressure Care Advice – please include the grade of sore and any manual handling issues.
5. Protection and Care of Joints
6. Hand Function
7. Manual Handling
8. Advice to Carers
9. Anxiety Management (where the patient presents with physical symptoms)
10. Rehabilitation Programmes
11. Falls Assessment
12. Mobility Assessment and Walking Aid Provision
13. Musculoskeletal Assessment and Treatment
Major Adaptations, e.g. level access showers and stair-lifts, should be referred to the Adult Community Care via Care Direct (0117) 9222700.
For NHS provision of wheelchairs please refer direct to Wheelchair Services (0117) 3403450.
Continuing Healthcare (CHC) - Fast Track Tool Referrals Form and Equality Monitoring Form
NHS Continuing Healthcare Fast Track Tool
To enable immediate provision of a package of NHS continuing healthcare
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Date of completion of the Fast Track Tool _____________________________
Name D.O.B.
NHS number:
Permanent address and Current location (i.e. name oftelephone number hospital ward etc.)
Gender _____________________________
Please ensure that the equality monitoring form at the end of the Fast Track Tool is completed
Contact details of referring clinician (name, role, organisation, telephone number, email address)
(please turn over)
Fast Track Pathway Tool for NHS Continuing Healthcare November 2012
To enable immediate provision of a package of NHS continuing healthcare
The individual fulfils the following criterion:
He or she has a rapidly deteriorating condition and the condition may be entering a terminal phase. For the purposes of Fast Track eligibility this constitutes a primary health need. No
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other test is required.
Brief outline of reasons for the fast-tracking recommendation:
Please set out below the details of how your knowledge and evidence of the patient’s needs mean that you consider that they fulfil the above criterion. This may include evidence from assessments, diagnosis, prognosis where these are available, together with details of both immediate and anticipated future needs and any deterioration that is present or expected.
When outlining reasons why a clinician considers that a person has a rapidly deteriorating condition that may be entering a terminal phase, the clinician should consider the following definition of a primary health need:
Primary health need arises where nursing or other health services required by the person are:
a) where the person is, or is to be, accommodated in a care home, more than incidental or ancillary to the provision of accommodation which a social services authority is, or would be but for the person’s means, under a duty to provide; or
b) of a nature beyond which a social services authority whose primary responsibility is to provide social services could be expected to provide.
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(continue overleaf)
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Please continue on separate sheet where needed. This should include the patient’s name and NHS number, and also be signed and dated by the referring clinician.
Name and signature of referring clinician Date
Name and signature confirming approval by CCG Date
Equality Monitoring Form
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About you (the patient) – equality monitoring
Please provide us with some information about yourself. This will help us to understand whether everyone is receiving fair and equal access to NHS continuing healthcare. All the information you provide will be kept completely confidential by the Clinical Commissioning Group. No identifiable information about you will be passed on to any other bodies, members of the public or press.
1 What is your sex? Tick one box only.
MaleFemaleTransgender
2 Which age group applies to you? Tick one box only.
0-1516-2425-3435-4445-5455-6465-7475-8485+
3 Do you have a disability as defined by the Equality Act 2010?
Section 6 of the Equality Act 2010 defines a person with a disability as someone who has a physical or mental impairment that has a substantial and long-term adverse effect on that person’s ability to carry out normal day-to-day activities.
Tick one box only.
YesNo
4 What is your ethnic group? Tick one box only.
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A WhiteBritishIrishAny other White background, write below
B MixedWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed background, write below
C Asian, or Asian BritishIndianPakistaniBangladeshiAny other Asian background, write below
D Black, or Black BritishCaribbeanAfricanAny other Black background, write below
E Chinese, or other ethnic groupChineseAny other, write below
5 What is your religion or belief?Tick one box only.
Christian includes Church of Wales, Catholic, Protestant and all other Christian denominations.
NoneChristianBuddhistHinduJewishMuslimSikhOther, write below
6 Which of the following best describes your
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sexual orientation?
Tick one box only.
Only answer this question if you are aged 16 years or over.
Heterosexual / StraightLesbian / Gay WomanGay ManBisexualPrefer not to answerOther, write below
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Continuing Healthcare and NHS Funded Nursing Care – Application for Consideration of Eligibility Consent Form and Multi-Professional Assessment Form - CM7
Name of patient: DOB:
Date of application: NHS No:
Current address:
Home address (if different from above):
General Practitioner:
I/my representative have had an explanation regarding this application and process for NHS Continuing Healthcare and NHS Funded Nursing Care. I also understand that this may affect any benefits and/or allowances that I am currently entitled to claim. I understand that any decision to award NHS Funding will be subject to continuous review.
Yes No
This consent form must be completed by either the individual to whom the application relatesto, or their legal representative.
I *do/do not wish to have my representative/advocate identified below present at my assessment/review (*please delete)
Representative Name:
Relationship:
Contact Number:
I agree that confidential information relating to the individual named above may be disclosed to the Clinical Commissioning Group reviewing the case, only in so far as is necessary for a decision to be made about this application and the arrangement of care. This information may not be used in relation to any other case or in relation to any other matter I may wish to raise with the Clinical Commissioning Group concerned.
Yes No
Consent to The Assessment Process & Information Sharing
The Mental Capacity Act set out the definition of a person who lacks capacity. These sections of the act say that a person lacks capacity if he, or she, has a temporary or permanent impairment of/or a disturbance in the functioning of the mind or brain when the
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decision needs to be made, and as a result is unable to:
Understand the information relevant to that decision Retain that information Weigh up information as part of the process of making the decision or Communicate his/her decision (whether by talking, using sign language or any other
means)
Where the person is incapacitated and unable to consent, information should only be disclosed in their best interests and then only as much information as is needed to support their care. For further guidance, see the Mental Capacity Act 2005 Code of Practice on www.dca.gov.uk/menincap/legis.htm and the guidance booklet “Making Decisions: a guide for people who work in health and social care” on www.dca.gov.uk/legal-policy/mental-capacity/mibooklets/booklet03.pdf
Mindful of this, who holds formal decision making responsibility?Self or Other?(as below)
Date of decision made:
Lasting Power of Attorney:
Level of Power
Health/Welfare
Financial
Deputy:
Enduring Power of Attorney:
Level of Power
Health/Welfare
Financial
Additional Information:
Advanced decision to refuse treatment: Yes No
Date decision made:
Located where:
If the person is deemed to have capacity:Has their consent been obtained for this assessment? Yes No
Have they given consent to have information shared with their NOK, main carer or advocate?
Yes No
Has their consent been obtained for sharing information contained within this assessment with potential care providers?
Yes No
If the person is deemed to not have capacity to consent, how was this determined?
How has it been decided, and by whom, that it is in the person’s best interests to complete this assessment?
Assessor: Designation:26
Signature: Date:
Signature of Assessed Person:
OR Signature of Assessed Person’s Representative:
MULTI-PROFESSIONAL ASSESSMENT – CM7IMPORTANTThis assessment should be undertaken by appropriate members of the Multi-Disciplinary Health Care Team. The overall responsibility for ensuring that this assessment document is completed rests with the designated health care professional who might be the nurse responsible for care on the ward, or in the community. The assessment will be used by social services or continuing health care to assist in formulating a care plan. This may result in formulating a
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package of community support services, day care, or providing care in a Residential or Nursing Home.
A. Patient Details
Surname……………………………..Forename(s)…………………………………………
Date of Birth……………………………………... NHS No: ……………………………………….Age…………………………………………………Address………………………………………………………………………………………………………………………………………………………………………...… Postcode...………………………Home Telephone ……………………………………Mobile ……………………………………………Closest Contact: ………………………………. Address: ………………………………………………………………………………………………….. Home Telephone: …………………………………Mobile: ………………………………………………GP Name: ………………………………………….. Address: …………………………………………………………………………………………………….. Telephone ………………………………………….District Nurse/Community Matron ……………………………………… Telephone……………….
B. Patient’s Current LocationConsultant:………………….. Hospital + Ward…………………….Reason for Admission: ……………………………………………………………………………………Date Admitted: …………………. Nursing Home/Temporary Location: ……………………………
C. Summary of medical history/diagnosis (with dates)To be completed by Consultant or designated Medical deputy
Name …………………………………………….. Designation ……………………………….Address ………………………………………….. Telephone …………………………………Signature ………………………………………… Date ………………………………………..
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D. Housing
Lives alone? Yes No Details (e.g. lives with) …………………………………………………………………………………………………………….
House Flat Bungalow Mobile Home
Sheltered/Extra Care Housing Residential Home Nursing Home
E. Details of Health and Social Care Professionals Currently Involved
E.g. CPN, CLDT, Social Worker, etc.
Name: ……………………………. Address: ……………………………. Telephone: ……………
Name: ……………………………. Address: ……………………………… Telephone: ……………
Name: ……………………………. Address: …………………………….. Telephone: ……………
Name: ……………………………. Address: …………………………….. Telephone: ……………
The information in this assessment document may be shared with the service user and their carers during discussions about the Care Plan. The information may also be shared with the providers of any services.
Please retain a copy in the health records.
1. CommunicationHow does this person communicate?
Verbally Sign Language Makaton Unable to reliably communicate Other Give details: ………………………………….
Language Spoken…………………….. Interpreter Required? Yes No
Does this person have dysphasia? Yes No What helps with effective communication? Give details:………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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2. Mental Health Does this person have a mental health diagnosis? Yes No
Diagnosis…………………………..
Date of diagnosis……………………………………
Folstein Score………………………………………..
Has a psychiatric referral been made? Yes No
Date of referral and to whom? ………………………………………………………………..
Please describe any behavioural issues (e.g. challenging, non-compliance, etc.) ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
How is this being managed – what helps? (re-assurance, medication, etc.) …………………………………………………………………………………………………………………………………………………………………………………………………………………………….
Please describe this person’s current emotional well-being (e.g. withdrawn, quiet, sociable) ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Please describe this person’s cognitive ability ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Has this person been assessed as having the mental capacity to decide where they live?
………………………………………………………………………………………………………………….
3. Management of Medication – tick all that apply
Self - Medicating Help Required Non-Compliant
Dossette Box Large Print Labels Needed
Names and dosage of current medication:
…………………………………………..........................................................................................
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
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4. Symptom control/monitoring Cause of pain ……………………………………………………………………………………… How is this person’s pain being managed e.g. positioning, comfort aids …………………………………………………………………………………………………………………..……………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Referred for pain management? Yes No Name of professional referred to: …………………………… Date of referral: ………………… Medication Required Yes No Frequency: ……………………… Other Symptoms – Give details: ……………………………………………………………………….…………….…………………………….…………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
Monitoring – Give details: (e.g. blood tests): …………………………………………………………………………………………………………………………………………………………………………………………………………… 5. Risk Factors e.g. falls, drug/alcohol abuse, safeguarding issues, challenging behaviour Give brief details: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Have Social Services been alerted to Safeguarding concerns? If yes, give details: …………………………………..………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
6. Environmental/Equipment Needs Have you been made aware of any issues/hazards within the home environment Yes No If yes please describe ………………………………………………….....................................................................................................…………………………………………………………………………………………………………………………………………………………………………………………………………………………
Has there been OT involvement? Yes No
Is an O.T. Home Visit Required? Yes No
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Any equipment required (e.g. raised toilet seat, etc.) give details: ……………………………………………….……………………………………………………………………………………………………………………………………………………………………………………
7. Personal Care Does this person require assistance? Yes No
How many carers are required? ……………………………………………………………………..
Bath/Showering Independent Requires help Describe help given: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
8. Skin Care/Wound Care (Please describe condition, treatment and care needed) ……………………………………………………………………………………………………………….………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………… Pressure Areas Does this person have pressure sores? Yes No Grade (European Pressure Ulcer Advisory Panel): Please describe (e.g. site and treatment): ………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………………………….
Responding to treatment? Yes No
Please describe care provided:
Positioning: ………………………………………………………………………………………………….. Equipment: …………………………….…..………………………………………………………………… Has a referral to Tissue Viability Nurse been made? : Yes No (if yes, include details in Part E above)
9. Foot Care Diabetic Yes No Blisters Yes No Hard Skin/Corns etc. Yes No Ulcers: Yes No Other (please describe) …………………………………………………………………………………….
32
……………………………………………………………………………………………………………… Is there a need for a chiropodist/podiatrist? Yes No Has referral been made? Yes No Date of Referral and To Whom: ……………..………………………… Use of Dressings, Ointments, Creams etc.
Please Describe ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
10. Oral Health Independent Yes No Does this person wear dentures Yes No Top set Bottom Set What assistance is provided with oral care ………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………………………………………………………………………
Has Dental Referral been made? Yes No
Date of Referral and to Whom: ………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………
11. Mobility Is this person independently mobile? Yes No Please note assistance required ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….
Transferring independently? Yes No Please note assistance required ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Hoisting required? Yes No Give details: …………………………………………………………………………………………………………….………………………………………………………………………………………………………………………
33
Managing stairs? Yes No Give brief details: ………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………
Has there been Physiotherapy involvement? Yes No Outcome: ………………………………………………………………………………………………………………. Aids used ……………………………………………………………………………………………………………….
How many carers required to assist?
Has this person fallen on the ward? Yes No If yes, how often…………………………………
Is there a history of falls at home? Yes No Details ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Has a falls assessment been completed? Yes No Has a referral to the falls adviser been made? Yes No Date and to Whom: ………………
12. Rehabilitation (to be completed by Therapists) Ongoing rehabilitation needed? Please describe (e.g. ICT, community rehab, community physio).
13. Continence Continent Incontinent if incontinent please see below
Urine Day Night Faeces Day Night
Does this person need prompting to use a commode? Yes No Does this person need prompting to use the toilet? Yes No
How are you managing their incontinence? ………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………
Stoma Care? Describe …………………………………………………………………………………….
Future Plan for Catheter Catheter In Situ? Reason for catheterisation: ……………………………………………… Date last changed: ……………………………………………………………………………………….. Need for aperients
Describe …………………………………………………………………………………… (e.g. laxatives)
34
Has a referral to a continence advisor been made? Yes No (If yes, include details in part E)
14. Vision Does this person have any visual difficulties? Yes No Is this person registered blind/partially sighted? Yes No Does this person wear glasses? Yes No
Does this person use aids? (i.e. magnifying glass, talking book, Braille) Describe ………………………………………………………………………………………………………….
Eye Care required? (e.g. use of creams)
Describe……………………………………………………………………………………………………………........…………………………………………………………………………………………………………………………………………………………………………………………………………………………
15. Hearing Does this person have any hearing difficulties? Yes No
Use of hearing aid Yes No Lip Reading Yes No Sign Language Yes No
Use of other equipment (i.e. communicators) …………………………………………………………………………………………………………………………….…………………………………………………………………………………………………….
16. Diet and Nutrition
Speech and Language assessment? Yes No Date and to whom referred: ……………………………………………………………………
Outcome recommended? …………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………….
Enteral feeding? Yes No Describe: ……………………………………………………………………………………………………..
Does this person require: Prompts to eat meals? Yes No Can they feed themselves? Yes No If no please describe help being given …………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………….
Has the O.T. recommended the use of any equipment? …………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………….
35
Does this person have any food allergies/intolerance/special diet? Please describe …………………………………………………………………………………………………………………………………………………………………………………………………………………………
Can this person prepare meals? (see O.T. assessment) Yes No
Weight on admission…………………….. Date……………………. Weight currently…………………….. Date………………….
17. Care at night – for completion by Night Staff Does this person have a sleep disorder? Yes No Give details: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Does this person require assistance at night time? Yes No Does this person require assistance with positioning at night? Yes No How often during the night is assistance needed and what help is given? ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Describe usual night time routine (ask patient or carer). ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Sedation: Yes No Describe: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………
18. Has this assessment been discussed with: The patient? Yes No The carer? Yes No Please record these views to assist the planning of services ………………………………………………………………………………………………………………………….…………………………………………………………………………………………………………
Please state reasons if no discussion has taken place …………………………………………………………..…………………………………………………………………………………………………………………………………………………………………………..
19. Patient’s Right to Continuing NHS Care
This patient has been screened against the National Framework for NHS Continuing Health Care eligibility. Both the referral and its outcome have been discussed with the patient/carer.
I can confirm this patient: Has Has Not been forwarded for a full NHS Continuing Health Care Assessment.
36
This patient has been referred for Fast Track Continuing Health Care Assessment
Health Care Professional co-ordinating this assessment:
Name …………………………………… Designation ……………………………………….
Address…………………………………. Telephone ………………………………………..
Signature ……………………………….. Date………………………………………………..
Bristol Dementia PartnershipDementia Wellbeing Service Referral Form (Care Homes with Nursing) Please Fax to: Central 0117 904 5155 North 0117 301 3919 South 0117 947 3129 email to [email protected] (must be from a secure email address) To make urgent contact or advice please telephone the access point on: 0117 9045151 available 8am until 8pm Mon-Fri and 9am-1pm Saturdays. Most Bank Holidays are also covered 9am – 5pm
PATIENT DETAILSFull Name: NHS No:DOB: Phone:Address & Postcode:
Contact details of significant other &relationship
GP Surgery
Informed of referral? Yes/no
Phone No. Address
REFERRER DETAILSReferrer
REASON FOR REFERRALIs an Interpreter required? ( Please specify language ) Yes / NoWhy are you referring this Resident to the service? Please include diagnosis current medication and significant health issues. Have you discussed this referral with the patient/family? What has been done so far?
Seen by GP/Physical examinations
Date?
37
Is this a referral for new assessment Yes No Please indicate perceived level of urgency:Emergency (consider 999, likely not for our service)Urgent- (48hr response)Non urgent 1-2 weekRoutine
Date Referred
Assessment of change Yes No
Advice/support only from Practitioner
Yes No
Dermatology Referral Form
Please complete both pages, save and then send to: [email protected], or post to the address at the end of this form.
PATIENT’S DETAILSPatient's surname …………………………………………….. Age …………..…..M/F…………..……
Patient's first name……………………………………………….. DOB ……../………/…………..
Name patient wishes to be known by………………………………… NHS No: ………………………
Patient/carer’s name…………………………………………………... Contact No: ……………………
Patient's address……………………………………………………….…………………………………….
……………………………………………………………………………Postcode…………………………
REFERRER’S DETAILS REGISTRATION DETAILS
Name ……………………………………………………G.P ………………………………………..……
Title …………………………………………………… Practice ……….……………………………..…
Contact address ……………………………………… Practice address ………………………………..
………………………………………………………... …………………………………………………..
Post code ………………………………………….…. Post code ………………………………………..
Phone No: ………………………………….………… Phone No: ……………………………………….
Email …………………………………………………. Email…………………………………………….
Fax No…………………………………………………. Fax No……………………………………………
38
PROTECTION/AT RISK DETAILSPlease complete if relevantName of social worker………………………………………………………………………………………
Social worker contact details…………………………………………………………………………………
Relevant information to be taken into account for this referral……………………………………………….
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………Do you wish to do a joint consultation Y/NPlease contact the office on the telephone number below if any details need to be discussed prior to appointment.
39
CLINICAL DETAILS
Diagnosis ……………………………………………………………………………………………………..
Length of time with symptoms ……………………………………………………………………………….
Areas affected …………………………………………………………………………………………………
Reason for referral ……………………………………………………………………….…………………..
(e.g.: further management / education / support) ………………………………………………………………
Current treatments …………………………………………………………………………………………….
…………………………………………………………………………………………….
Past prescriptions ……………………………………………………………………………………………..
…………………………………………………………………………..…………………Further Information
To include PMH, medication and allergies
Signature………………………………. Date ………………………………
PLEASE SEND TO Primary Care Dermatology Service,William Budd Health Centre, Knowle West Health Park, Downton Road, Knowle
Bristol, BS4 1WH TEL: 0117 944 9782 / 0117 944 9783Email: BRCM@[email protected]
40
Deprivation of Liberty Safeguarding Referral Form
If you believe that a crime has been committed please call the Police on 101 for further advice and email or fax a copy of this form to Bristol Care Direct
Client details
Name PARIS / RIO No.
Date of birth Gender Ethnicity
Permanent address GP name and practice details (including address)
Unit / Ward
(if applicable)
Referrer details
Name of referrer
Relationship to
adult at risk
Contact tel. no. Organisation / Company (if applicable)
Contact email
Details of concern or incidentDate of incident Date reported
Placement address at the time of the incident
41
Safeguarding Adults Referral Form
This form should be faxed / emailed to:
Bristol Care Direct
Fax: 0117 9036688
Email: [email protected]
M
F
Residential / nursing home
(if different from above) Type of service provided at the placement
(if applicable)
If Domiciliary Care please specify which agency
Dom Care Unit / Ward
(if applicable)
Summary of incident / concerns
What type of abuse is being referred?
Relationship of alleged perpetrator to the adult at risk
Is this domestic abuse?
Is this a hate crime?
Further informationIs an urgent response required today?
Is the person aware of this referral?
42
Extra care housing
Supported living accomodation
Sheltered housing
Hospital Hostel Other
Physical Financial Discriminatory Sexual
Neglect
Institutional Psychological
Self-neglect
Partner Other family Neighbour Friend Fellow resident
Landlord Employee Volunteer Stranger
Social care worker (including social workers, care managers, home care assistants)
Health care worker (including GP's, nurses, consultants) Other professional
Yes No Yes No
Yes No Yes No
Other notified agencies
Other agencies involved with the care of the adult at risk
Source of funding
Any known views of the service user / carer? Has the adult at risk consented to the referral being made? Have they said what they wish to happen?
Details of any previously reported concerns
43
Police CQC Funding authority / Other LA (if necessary)
BCC CCG Direct payment Supporting people Self funded
Other authority (please specify)
Diabetes and Nutrition Services Referral Forms A & B and Equality Monitoring Form
BCH Diabetes & Nutrition Services REFERRAL FORM A
For Diabetes Referrals Only
Diabetes & Nutrition Services (DANS) John Milton Clinic Crow Lane, Bristol, BS10 7DP Tel: 0117 9598970 Fax to: 0117 9598971 Email to: [email protected]
Please use this form for Diabetes referrals only Please complete with as much detail as possible, including the equality monitoring form.
Date of Referral: GP’s Name:
Referred by: GP Practice and Address:
Patients details: Title: NHS Number:
First Name:Date of Birth:
Last Name:Male Female
Address:
Postcode:
Daytime Phone Number:Mobile Number:Email Address:
Preferred Contact Options: (please provide details)
Post Phone Text
Relevant test results:
date taken:
eGFR ml/min
44
Patients First Name LAST NAME
Please send to:
Relevant test results:
Date taken:
Fasting blood glucose
mmol/l
HbA1c mmol/mol
HDL mmol/l
This form should be completed by the referrer. The person you are referring must be informed that their details are being forwarded to the Diabetes & Nutrition team office.
Blood pressure
mmHg
Weight kg
Height m
BMI kg/m2
Waist circumference
cm
Other: (please state)
Social / Activity levels: Special Needs? e.g. wheelchair access, language interpreter, special diet, hearing loop, learning difficulty, etc. Yes No Please Specify:
DANS Referral Form A Jan 2014
Diabetes Diagnosis: Type 1 Type 2 Other: (please specify):
Date Diagnosed:
Diabetes Treatment(s): Diet and Activity Diet, Activity and Medication: (include details
of type & dose)
Oral Hypoglycaemic tablets:
GLP1: Insulin:
Other Relevant Medical History:
Any Known allergies?
Other Relevant Medications:
Other comments:
Reason for referral: Please tick box(es) of service or all 3 services you require if appropriateEducation sessions: Living with Diabetes Information pack given? Yes No
1 day course for people newly diagnosed with Type 2 diabetes (within the last 12 45
months) with option of ½ day follow up 6 months later. (Please complete a referral form even if your patient declines to attend and advise us “DECLINED AT SURGERY”)
Can I Eat Bananas? 2 day course for people with Type 2 diabetes who have started on Insulin treatment.
Carbohydrate Awareness 3 hour group introducing carbohydrate counting, how it can improve diabetes control and what is involved.
Food Freedom Intensive Type 1 carbohydrate counting course run for 1 day a week for four weeks for patients on basal bolus insulin regime.
Skills for Life Living a healthy life and sharing experiences – course for Type 1’s. Run for 3 hours a week for 6 weeks.
Dietitian Please use Nutrition & Dietetics referral form B if not diabetesNewly diagnosed (type 2 diabetes)Existing Type 2 diabetesCarbohydrate counting (type 1 diabetes)Reduce lipids
Reduce weight
Diabetes Nurse Specialistto start/has started insulin/GLP1 (please select) insulin switch assessment
hypo/hyperglycaemic management (poor control)
For office use only: D. Ed Dietetics DSN
DANS Referral Form A Jun 2013
If you have any queries, please telephone us on 0117 9598970
Equality Monitoring Form
46
Bristol Community Health wants to provide you with a good service. It can only do this if it understands who its patients are. We hope you will help us by filling in the following questions. The information you provide is confidential and will be used for monitoring purposes only.
1. How old are you? Please tick one of the following 15 & under 16 – 24 25 – 44 45 – 64 65 – 74 75 & over
2. What gender are you? Please tick one of the following Female Male
3. How do you describe your ethnic origin? Please tick one of the followingBlack or Black British African Caribbean
African Somali
Other Black (please describe):
Chinese or Chinese British Chinese
Dual heritage / Mixed race) Asian and
White Black African and White
Black Caribbean and White
Other mixed (please describe):
South Asian or South Asian British Bangladeshi Pakistani
Indian Other Asian (please describe):
White British Irish
Gypsy/ Romany/ Traveller
Other white (please describe):
Polish
Other ethnicity (please describe):
47
48
4. What is your preferred language?
5. How do you describe your religion/ belief? Please tick one box (or write, if “other”)
Buddhist Christian Hindu Jewish Muslim Sikh
Agnostic Other – please describe:
None Prefer not to say
6. Do you consider yourself to be a disabled person?
(The Disability Discrimination Act defines disability as “a physical or mental impairment which has a substantial and long-term adverse effect on your ability to carry out normal day-to-day activities”.)
Yes No
If you have answered “Yes”, please tick any of the following that apply to you.
Mobility issues Physical impairment (describe):
Visual impairment (not corrected by glasses/ contact lenses) Learning difficulty (describe):
Hearing impairment Mental health needs (describe):
Living with a progressive condition e.g. multiple sclerosis, cancer Another cause (describe):
Prefer not to say
7. How do you describe your sexual orientation? Please tick one of the following
49
Bisexual Gay Man Heterosexual/ Straight Gay Woman/
Lesbian Other Prefer not to say
Thank you for answering these questions
Diabetes & Nutrition Services
50
L
REFERRAL FORM B
For Nutrition & Dietetic Referrals Only
Please send to: Diabetes & Nutrition Services (DANS) John Milton Clinic Crow Lane, Henbury, Bristol, BS10 7DP Tel: 0117 9598970 Fax to: 0117 9598971 Email to:[email protected]
Please use this form for Nutrition & Dietetic referrals only Please complete with as much detail as possible, including the equality monitoring form.
Date of Referral: GP’s Name:
Referred by: GP Practice and Address: :
Patients details: Title: NHS Number:
First Name: Date of Birth:
Last Name: Male Female
Address:
Postcode:
Daytime Phone Number:Mobile Number: Email Address:
Preferred Contact Options: (please provide details)
Post Phone Text Email
Relevant test results:
date taken:
Fasting blood mmol/l
Relevant test results:
date taken:
51
This form should be completed by the referrer. The person you are referring must be informed that their details are being forwarded to the Diabetes & Nutrition team office.
glucoseHDL cholesterol mmol/l
LDL cholesterol mmol/l
Total cholesterol mmol/l
Triglycerides mmol/lOther investigations e.g.: coeliac screen
eGFR ml/min
Blood pressure mmHg
Weight kgHeight m
BMI kg/m2
Waist circumference cmOther: (please state)
Social / Activity levels: Special Needs? e.g. wheelchair access, languageinterpreter, special diet, hearing loop, learning difficulty etc, Yes NoPlease Specify:
Diagnosis:
Date Diagnosed:
Treatment(s):
Other Relevant Medical History:
Any Known Allergies?
Other Relevant Medications:
Other Comments:
Reason for referral: NB: Please use this form for Nutrition & Dietetics referrals only.
For diabetes referrals please use form A
IBS Known Coeliac disease Reduce lipids Nutritional deficiencies (please specify)
52
Reduce weight (must have a co-morbidity) Malnutrition (“MUST” screening tool nutrition risk score ≥ 2) Impaired glucose tolerance Other gastric (please specify) Other (please give details)
Has any dietary information already been given? Yes No Please give details:
For office use only:
DANS Referral Form B Jun 2013
If you have any queries, please telephone us on 0117 9598970
53
Falls Specialist Nurse (BCH) - Multi Factorial Falls Risk Assessment Tool Form
Patient Name:NHS No: DoB:Form Completed By: Time:
Signature: Date:
Description of Circumstances Actions1. History of FallsNumber of falls in the last Year Month Consider referral to rapid response if
risk of hospital admission. Does this patient need comprehensive geriatric assessment?
Week Is this a new problem Yes No
Circumstances e.g. inside, outside, what was patient doing
Any associated symptoms e.g. light head, dizziness, blackouts Yes No If unexplained fall, blackout or
new arrhythmia consider specialist geriatric assessment –discuss with GP
Record pulse Arrhythmia Yes No
Did patient know they were falling Yes NoUnable to get up Yes No If yes Physio and / or OT referral
required following discussion with GP, Community Matron or CNOP. Care direct for information on personal alarms
Any near miss or falls back onto sofa or bed Yes NoUnable to summon help Yes No
Could this patient be acutely unwell Yes No Discuss with GP or integrated nursing team as appropriate.
Fear of falling Yes No Consider OT and physio. Give staying steady and what to do if you fall leaflets
2. Medications4 or more medications?Include over the counter drugsAntidepressants / Anti-psychotic / Sedative / Blood pressure / Diuretic / (Circle)
Yes No Consider referral for medication review by GP, pharmacist or community matron
Recent changes in medication Yes NoTaken as prescribed Yes No3. Postural HypotensionLighthead or dizziness on standing or getting out of bed
Yes NoPostural Hypotension if drop of 20mm Hg on systolic (top number),drop of 10mmHg on diastolic (bottom number) or if systolic Check lying to standing BP after lying for 10 mins
54
is lower than 90mmHg.
Lying Standing at 1 min
Standing at 3 mins
4. Alcohol Intake - units of alcohol consumed If more than 1 unit per day use brief intervention tool to discuss likely harm to patient
Per day Per week
5. Nutrition and OsteoporosisUse MUST flowchartDiscuss calcium and vitamin D intake Check dentition and refer to dentist if needed
Discuss with GP
Height Weight BMIUnplanned weight loss in last 3 – 6 months? MUST Score = Yes No
Indigestion Yes No
Patient Name: NHS No:Calcium & Vitamin D Yes No
Check taking correctly
Check FRAX and discuss with GP
Bone sparing agent e.g. bisphosphonate Yes NoIf no bone protection- did parent fracture hip Yes No -premature menopause Yes No6. Vision Date of last eye test Eye test more than 1 year ago or
deterioration in vision - prompt eye test (information on home eye tests if needed) Use Eyes Right Screener if patient reluctant to attend eye test Find correct glassesSuggest discussion of vision and falls with optometrist
Has vision deteriorated since last eye test Yes No
Wearing incorrect glasses Yes No
Not wearing prescribed distance glasses or wears bifocals or varifocals
Yes No
7. HearingDifficulty with hearing conversational speech Yes No Check for wax
Refer back to audiology if known to this service or refer to GP for initial referral
Assessment required for hearing aid Yes No
8.Walking / GaitUnsteady on feet or shuffles taking uneven steps or holds on to furniture
Yes NoCheck if previous physio referral. If not consider referral to Physio /group*. If yes, request last therapy discharge from GP/ RiO to see if further intervention appropriateConsider podiatry referralUrgent referral to GP or Rapid Response unless longstanding medical reason for this.
Obvious foot problems. Please look at bare feet as able Yes No
Is it unsafe to walk patient Yes No
9. Transfers If manual handling problems identified consider referral for Physio and/or O.T. If problem is urgent may require Rapid Response.
Has difficulty with or appears unsteady Yes No when transferring with or without a carer
10. FunctionConsider OT referral and equipment Difficulty with ADLs e.g. washing / dressing /
food preparation / stairs /Yes No
55
needs
Are strategies already in place Yes No
11. ContinenceUse symptom profile and access continence pathway
Urgency Nocturia FrequencyDaily fluid intake12. Environmental Hazard Educate patient regarding potential
risks of falls. Advise/refer patient to Care & Repair, Home adaptations team (via Care Direct)
Any obvious hazards
13. CognitionProblems with forgetfulness over the last 12 months that have caused patient significant problems
Yes No Use cognition test if patient willing Discuss with GP
Outcome: Referrals to GP CM CNOP OT CRT Podiatrist PharmacistFalls Nurse Specialist Care Direct Rapid Response Rehab CentreDietician Dom Physio *Strength & Balance
groupCare and repair Dentist
Other
Leaflets Given Staying Steady What to do if you fall Other: specify
Abnormal blood resultsForm Completed By: Time:
Signature: Date:
Multi Factorial Falls Risk Assessment January 2015 – produced by Bristol Community Health
56
Palliative Care Services - Bristol Care Coordination Centre (Coordinating end of life care)
Date: Time: Source (i.e. Phone/Fax/email):Referral Form
Forename:Surname:Preferred Name:NHS NumberPatient Address:
Postcode:Contact Telephone Number(s): Home: Mobile:
D.O.B:Age:Gender:Ethnicity:Does the patient live alone Yes ☐ No ☐(if No, with whom?) Name/Relationship:Current Location of Patient Home ☐ Hospital ☐ Other ☐
Hospital:SiteContact Details
Other:PlaceContact Details
Referrer Details:(Name, Designation,Address, Tel Number)
GP GP Details: (Name, Practice Name, Address, Tel Number) Key Worker Details: Name, Designation, Address, Telephone Number
Involvement in Care(Please give details)Consent for Referral Yes ☐ No ☐ N/A ☐DNAR Order in Place Yes ☐ No ☐ N/A ☐Preferred Place for CarePreferred Place of Death
Religion (Please state)Sexual Orientation Heterosexual ☐ Gay ☐ Lesbian ☐
57
Bisexual ☐ Other ☐
Medical/Diagnostic details
Diagnosis
Any Concurrent illnesses
Prognosis (Hours, days, weeks)
Estimated By (Name/Role)
Is the patient aware of prognosis?
Are the relatives aware of prognosis?
Any Further Comments:
Syringe driver and/or injectable medication prescribed/in place?Anticipatory Medication: Prescribed/ In place?
Any known Allergies?If Yes please provide details
Date of Risk Assessment / Care Plans
Location of Risk Assessment / Care Plans
Keysafe Number
Parking/Access DetailsAny issues please specify
Home/Environmental Risks(Pets, Smokers, Other)
58
If other please provide details
Carer/Family/Significant Relationship Details
Name:
Relationship:
Contact Tel Number:
Address: (leave blank if same as patient)
Involvement in care and/or support ofpatient
Care Needs (please add as much detail as possible)
Mobility (in/out of bed)
Eating and Drinking
Personal care (hygiene and comfort)
Continence Yes ☐ No ☐
Is a catheter present?
Communication
Day times needs Yes ☐ No ☐ Details
Night time needs Yes ☐ No ☐ Details
Carer respite needs
Nursing needs (specifically requiringregistered nursing involvement)
59
Any uncontrolled symptoms
Any other factors
Equipment in place/required to support above care needs
Any specific services/referrals required?
Palliative Care Patient Referral Form - St Peters Hospice
60
PLEASE COMPLETE BOTH PAGES
Charlton Road, Brentry Bristol BS10 6NL
Tel: 0117 915 9495 Fax: 0117 981 1405
Email: [email protected]
Please also enclose copies of any relevant hospital letters/reports– lack of information will delay referral
Surname:
Fore name:
D.O.B:
Title:
Marital status:
Address:
Postcode:
Tel No:
Mob No:
NHS No:
Occupation:
Religion:
Ethnic Group:
Next of kin:
Name:
Relationship:
Address:
Postcode:
Tel no:
Mob no:
Main carer:
Address (if different):
GP:
Practice Address:
DN:
Base Address:
61
Tel. No:
Fax No:
Tel. No:
Mob. No:
GP consent to referral: Yes / No
Patient consent to referral: Yes/ No
(N.B. without consent the referral cannot be accepted)
Current location of Patient:
Do we need to contact the referrer prior to making contact with patient?
Yes / No
URGENCY OF REFERRAL: URGENT □ (contact within 2 working days of receipt) ROUTINE □ (contact within 2 weeks of receipt)
If you are seeking a response outside these parameters, please call the Referrals Team on:
0117 915 9495.
SERVICE REQUESTED (see guidance notes):
Home Visit –Community Nurse Specialist
□ (with/without GP/DN) IPU Admission □
Home Visit –Doctor □ (with/without GP/DN) Day Hospice □
Medical Op Appointment
(Can be one off)□
Fatigue Management – use separate referral form
All REFERRAL FORMS available via our website: www.stpetershospice.org
For Office Use Only: Date received………………………………………..
Received by C/T…………………………………….
62
Patient’s name:……………………………
MEDICAL DETAILS
Primary diagnosis:
Date of diagnosis:
Other medical conditions:
Known metastases: Adverse drug reactions/Allergies
Internal Defibrillator: Yes / No
Pacemaker: Yes / No
Consultant(s): Hospital: Hospital number:
SUMMARY OF DISEASE AND TREATMENT TO DATE
Please also enclose copies of any relevant hospital letters/reports– lack of information will delay referral
63
Reasons for referral:
Assessment for hospice admission □ Emotional/psychological
support □
Pain/symptom control □ Carer support □
Other (please state)……………………………………………………………………………………………….
Current problems and specific aims of referral to hospice Specialist Palliative Care team:
Patient and family insight:
Are you aware of any significant conversations about advance planning/preferred place of care? Please specify:
Signed: ………………………… Place of work/department: …………………...
Print name:………………………………….
Tel no: ……………………
Mobile No.………………..
Designation:………………………………... Date:………………………………
64
Parkinson’s Nurse Specialist Referral Form Please Refer to the PNS Criteria and Complete All *Mandatory Fields before Submitting
Patient Details*Surname: *Forename:
*Title: Mr Mrs Miss Ms other (state) *Date of Birth: *Age:*Address:
*Post Code:*Telephone No:
*Ethnicity:
*GP Name: *NHS No:*GP Practice & Address:
*GP Telephone No: *GP Fax:*Next of Kin Name: *Relationship to Patient:*Next of Kin Address:
*Telephone No:*Is The Patient Known To The PNS Yes NoParkinson’s History*Date Diagnosed:*Name of Parkinson’s Consultant /Specialist: (If any)*Reason for Referral:
*Current Parkinson’s Medication:
*Previous Parkinson’s Medications/Sensitivities:
65
*Other (Non-Parkinson’s) Medications:
Patient History*Other Medical Conditions:
*Does the Patient have any Cognitive Impairment or Dementia?
*State the Patients Level of Mobility:
*Does the Patient have any Communication Needs?
*Any Relevant Social History / Circumstances:
Multidisciplinary Team InvolvementPlease Provide Name and Contact Details : (If Known)Physiotherapist:Occupational Therapist:Speech & Language Therapist:Social Services:
Other: (Psychiatry/Memory Clinic/Continence/Dietician/Podiatry)
Referral*Have you followed the referral criteria and the anticipatory care management guidance located at; http://www.briscomhealth.org.uk/our-services/parkinsons-nurse-specialist
Yes/No: If no please state the reason why:*Is there any possible risk to the nurse seeing the patient in the clinic/ or home environment? Yes/No: If yes, please state why:Before submitting please consider whether this referral may be more appropriate for another discipline: e.g. difficulties with swallowing refer the patient to SLT.Each referral will be assessed and prioritised by the PNS according to the needs of the patient and within the confines of the service and resources available*Name of Referrer:
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*Designation: *Tel No:
E-Mail:*Location/Contact Details:
*Signature: *Date Submitted:
*Is the Individual Aware of the Referral? Yes : No:
Submit to; Kay BaggleyParkinson’s Nurse SpecialistKnowle ClinicBroadfield RoadKnowleBristol BS4 2UH
Tel. 0117 919 0289Fax: 0117 919 0296
Email: [email protected]
Office Use:Date Referral Received: Date Patient Contacted
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Podiatry Clinic Referral Form
V2
Podiatry Clinic Referral Form V6 July 2014
Please return your completed form to: Podiatry Department, Knowle Clinic, Broadfield Road, Knowle, BS4 2UH Tel: 0117 919 0275 Fax: 0117 9 190 259
Please complete all the sections of this form. If we require more information to process your application we may return this form to you. Please make sure that you provide a day time contact telephone number.
WE DO NOT PROVIDE A TOE NAIL CUTTING SERVICE.
All treatment will be based on medical & podiatric need.
PATIENT DETAILS
Title Forename
Surname
D.O.B Male/Female
If under 18 do you have a social worker yes/no
Tel no home
Tel no work
Mobile
If you do not wish to receive a txt reminder of your
Appointment please tick this box.
Address
Post code
68
E mail
NHS No
Interpreter Required Yes No
Language Spoken
NEXT OF KIN GP DETAILS
Title Forename
Surname
Address
AddrePost code
Relationship
Telephone no
Doctor
Practice Address
Telephone no
PLEASE TURN OVER TO COMPLETE REVERSE OF FORM
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Patients Name: ……………………………………. ……. NHS: ………………………………………..
Do you have an open wound on your foot? (Delete as appropriate) YES / NO
If YES please give details:
If NO Please tell us as much about your thoughts on your foot problem as you can:
My main foot or nail problem is:
Medical History - Please list or attach print out from GP Surgery:
Allergies:
Medication - Please attach a prescription or provide a list of all medications
(include any that you may self prescribe):
Additional Information: Please complete as much as possible:
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DiabetesYes / No Last HBA1c:
Last foot screen resultLow / Increased / High / Ulcerated
NeuropathyYes / No Peripheral
arterial disease Yes / No
Is the patient receiving treatment at any hospital? – please provide details
Yes / No
Completed by: Podiatrist GP Nurse AHP Guardian Self
Signed Contact Tel no: Dated
Name Printed
Office Use only:
Date received Triaged by & date
Priority status Urgent Routine . Diabetic
V2
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Speech and Language Therapy Service Referral Form (Adult)
Please do not refer if the person also requires occupational therapy/physiotherapy (refer to SLT within Bristol Community Health).
PATIENT DETAILS REFERRER DETAILS
N.H.S. No: Name:
D.O.B.: GP Practice:
Surname: GP Telephone No.:
First Names:
Address:
Postcode:
Telephone No. Contact No. & person, if not the patient:
First language:
Ethnicity:
Requires transport: Yes / No Requires home visit: Yes / No
To aid triage please give as much information as possible
Medical Diagnosis:
Reason for Referral:
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Priority: Urgent / Routine
(delete as applicable)
Medical History and Medication
(separate GP medical history and medication sheet may be attached)
Risks (please delete as appropriate)
Lives alone: Yes / No
Significant change in swallow and/or communication: Yes / No
Choking: Yes / No
Current safe guarding concerns: Yes / No
Email completed form to: [email protected]
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Wound Care Service Referral Form
Wound Care Service Referral FormPlease return the completed form to the Wound Care Service at
Knowle Clinic by fax - 0117 9190370
Failure to complete this form fully may result in the referral being delayed Patient details:
Name: NHS number:
Date of birth: Ethnicity: Address:
Telephone: Land:
Mobile:
Postcode:Referral Information:Date of Referral: Date
received:EMIS No:
Referring person: (& role)Name
Address:
Telephone:Priority weighting 1 or 2 (see referral criteria)
Service required from WCS: - home visit / clinic appointment / telephone advice / other
Has the patient been seen by WCS previously? Yes / No / Not sure
GP details:GP name, address, telephone and fax:
GP code (if known):Patient next of kin:Name: Address:Telephone:Postcode:
Wound information: Type of wound:- leg ulcer / surgical wound / pressure ulcer / otherMedical history: (if medical summary attached then no need to complete
this section)Diabetes:Rheumatoid arthritis / inflammatory disease:Infection or cellulitis present:
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Recurrent cellulitis:Major surgery:Vein surgery / DVT:Other significant medical history:Allergies:Significant medication:(if possible please include list of
medications)
Patient Name: NHS Number:
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Reason for referral to Service:
Wound - site, description, measurements, duration and previous wound history:
Current dressings / bandage regime used:
Information related to wound: Any problems with past dressings, treatments, concordance or other issues
If leg ulcer - last Doppler results Inc. sounds, date and where (if available send Leg Ulcer Care Pathway):
Ankle circumferences:
If pressure ulcer suspected: Category:- 1 2 3 4 unknown (please indicate)
Any other Services involved with patient: (please indicate) eg - Community Nurses, Practice Nurses, Podiatry, Community Matron, Secondary Care, Dermatology, others
Has patient been referred to any other Service: (please indicate) e.g. - Dermatology, Vascular, Plastics, Podiatry, others
Please return the completed form to the Wound Care Service at Knowle Clinic by fax - 0117 9190370
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