Address: / DOB: / Age:
Ward: / Consultant
Preferred name: / Tel:
Care Coordination Centre Referral Form (District)
Private Bag 1921, Dunedin
Phone (03) 470 9300 (Internal 9300)
Fax 0800 435 166 (03) 470 9506 (Internal 59506)
NZ resident? Yes No Ethnicity:Language used: Interpreter required? Yes No
Has the person consented to this referral and the sharing of information? Yes No Reason
Next of kin/caregiver/support person name:
Address:
Telephone/s:
Relationship:
Enduring Power of Attorney: Yes No Has EPOA been invoked? Yes No
Comments:
Community Services Card? Yes No
Number: 00000/
Expiry Date:
ACC claim? Yes No
Claim number:
Date of Injury: / GP:
GP Practice:
Is there an able-bodied person in the home? Yes No Unknown
Date of discharge from hospital (if applicable):
When is service to commence?
When is service to end?
to be completed for DUNEDIN CLIENTS REQUIIRING community nursing
Please attach the following (where appropriate)
Discharge summary
Copy of prescription
Negative Pressure Wound Therapy (NPWT) checklist
Peripherally Inserted Central Catheters (PICC) / Medication list
Stomaltherapy Discharge Sheet
Other relevant information e.g. wound care information ABPI (Ankle Brachial Pressure Index)
to be completed for dunedin clients requiring Community Nursing and Community Allied Health Services
Please attach additional information (where appropriate)
Community Nursing; including
- Continence
- Stomaltherapy
- Oncology District Nursing / Dietician
Early Discharge Rehab Service
Meals on Wheels
Occupational Therapy / Physiotherapy
Speech Language Therapy
Other
Please rewrite client details
Surname:
First names:
NHI:
Support Allocation Tool Please complete this tool to inform whether client is complex or non-complex YES NO
1. Does the client have a cognitive impairment?
(Decreased ability to think, concentrate, formulate ideas and remember that impacts on
everyday life)
2. Does the client have a progressive neurological condition?
(Conditions that get worse as time goes on (e.g. Alzheimer’s, Parkinson’s disease & Multiple
Sclerosis))
3. Is the client’s carer/s unable to continue caring for the client or feeling
overwhelmed or distressed?
4. Does the client require assistance with getting dressed?
5. Does the client require assistance with medication management?
6. Does the client have unmanaged pain that significantly impacts on daily living?
7. Does the client have anxiety, low mood or other mental illness that
significantly impacts on daily living?
Answering YES to ANY of the questions indicates that the client is complex.
Mobility
Independent
Stick
Crutches
Frame
Wheelchair
Other
Speech
Good
Impaired / Cognition
Alert & rational
Mildly confused
Intermittent confusion
Very confused / Bowels
Continent
Incontinent
Bladder
Continent
Incontinent
Catheter / Hearing
Good
Impaired
Skin Integrity
Intact
Broken
At risk / Sight
Good
Impaired
Nutrition
Good
Compromised / ALERTS
Infectious
Dog at home
Allergies
Safety risk
Falls risk
Other
Medical Condition/Diagnosis:
Please rewrite client details
Surname:
First names:
NHI:
to be completed for palliative clients
Please complete the following questions and attain signature:
The person is in the terminal phase of their life (with a prognosis/life expectancy of less than three months)
The person requires Hospital Level Care placement OR Domestic Assistance and/or Personal Cares
Senior Medical Officer/Hospice Doctor/ GP (if no SMO or hospice involvement): I agree with the above statements:
Name (print) Signature Date
to be completed for ALL CLIENTS BEING DISCHARGED FROM HOSPITAL (DISTRICT WIDE) AND palliative clients REQUIRING domestic assistance and/or personal cares
Domestic Assistance / Personal Cares
Kitchen
Meal prep – Breakfast
Meal prep – Lunch
Meal prep – Tea
Change bed linen / Laundry
Bathroom
Toilet
Vacuuming
Wash floors / Bathing / showering
Dressing / undressing
Eating / drinking
Personal hygiene
Medication Management / Walking / locomotion
Safety checks
Skin care
Toilet use
Transfers
Home & Community Support Services (HCSS) Package of Care:
Service / Allocation
Domestic Assistance / hours per week
Personal Care / hours per week
Client’s preferred Home and Community Support Service Provider?
No preference Royal District Nursing Service NZ FAX: 09 589 1081
Healthcare of New Zealand FAX: 0800 001 996 Access Homehealth FAX: 0800 161 445
Referrer/assessment completed by (please print): Date of referral
Designation and ward / department / organisation:
Phone
Fax
For CCC office use only: / Referred to:
Priority: / £ Urgent / £Semi urgent / £Routine / Signature:
Complexity: / £ Non-complex / £ Complex / Date: / Time:
For HCSS PROVIDER use only: / Name of provider (branch):
Referral accepted: / £ Yes / £ No, why? / Acknowledged by (print name):
Confirmed start date: / Date:
Southern DHB 19282 V13 Issued: 01/07/2013 Clinical Record Page 3 of 3