Guideline for Completion of a Regional Form

Guideline for Completion of a Regional Form

Day Hospital Referral

1.0 Form Purpose:

The purpose of the Day Hospital Referral Form is:

1.1  To provide accurate and consistent referral information to the appropriate Day Hospital Site

1.2  To facilitate effective assessment and treatment goals regarding referrals to the Day Hospital Program.

2.0 Definitions:

2.1 Referral: Request for the recipient of the referral to ensure provision of care to the individual.

2.2 Day Hospital Program: A program that provides assessment and rehabilitation services to promote health living for elderly clients in the community.

2.3 Contact Person: Refers to informal care provider

2.4 Health Agencies: Various health care providers/agencies/programs that may provide relevant collateral information.

3.0 Used By:

3.1 Any primary health care provider. Referrals from health care professionals should be forwarded to the primary care provider for their agreement/approval.

3.2 Hospital Inpatient Units, Emergency Departments and Geriatric Programs.

4.0 Guidelines for Completion:

4.1 Upper left box: Referral Source indicates program site location determined by client’s home address and faxes completed referral form with required information (*refer below).

4.2 Upper right box: Addressograph or label may be used.

4.3 Client Information Section:

4.3.1 Is the referral urgent? If Yes, WHY?: Circumstances that warrant a response within 10 working days.

4.3.2 Address and Postal Code: Home address and postal code in the community where client resides

4.3.3 Phone Number: At client’s home address.

4.3.4 Date of Birth: The day, month and year client was born.

4.3.5 Health Card Number: Six digit Manitoba registration number.

4.3.6 PHIN: Nine digit Personal Health Identification Number.

4.3.7 Contact Person: Name of an informal care provider or Next of Kin.

4.3.8 Relationship: Describe how the client is connected to the contact person.

4.4 Health Agencies:

4.4.1 Physician, phone, fax: Indicate name, phone, and fax of primary care provider in the community.

4.4.2 Home Care Coordinator, phone, fax: Indicate name, phone, and fax of community case coordinator (in hospital or home).

4.4.3 Other Agencies Involved/Consulted (attach reports): Check as many as necessary and indicate name and phone number. Attach any relevant collateral information.

4.5 Clinical Information:

4.5.1 Diagnosis/Active Problems: Indicate all medical diagnostic information; describe any active problems of concern regarding the client.

4.5.2 Past Medical History: Describe past events
and circumstances that are or may be relevant to a patient's current state of
health.

4.5.3 Recent Hospitalizations: Date and location of previous hospital admissions.

4.5.4 Current Medications, Allergies and Diet: Attach information if applicable.

4.5.5  Reason for Referral: Indicate what issues need to be addressed.

4.5.6  Required Information: Provide any relevant diagnostic test results, occupational therapy and physiotherapy assessments, social history and consultation reports.

4.5.7  Patient is Aware and in Agreement with this Referral/Physician Aware: Indicate Yes or No.

4.5.8  Name of Referring Agency, Referral Coordinated By, Phone Number: Name of agency/program and phone number the referrer is representing.

4.5.9  Signature of Referring Source: Signature of individual named in “referral coordinated by”.

4.5.10  Date of Referral: Date referral form is completed.

5.0 Filing/Routing Instructions:

5.1 Referral source refers to map on reverse side of Day Hospital Referral Form, for correct Day Hospital location.

5.2 The referral form is faxed by referral source and reviewed by receiving Day Hospital Program Intake team.

5.3 If referral deemed appropriate, information is entered on RGITS (Rehab and Geriatric Intake Tracking System) and placed on the Central Wait List. A wait list and patient reference identification number is assigned.

5.4 Once the referral is accepted into the appropriate Day Hospital program, client is taken off the Central Wait List on RGITS (Rehab and Geriatric Intake Tracking System) and a Day Hospital chart is initiated.

5.5 The referral form is filed on the facility health record of the accepting Day Hospital.

5.6 The Day Hospital program will redirect referral when an alternate service or catchment is required.

6.0 References/Resources:

6.1 WRHA - Regional Day Hospital Coordination Committee