Referring Source

Hamilton General Hospital  Henderson General Hospital  St. Joseph’s Hospital Date:______

MUMC/Chedoke McMaster  CCAC  Other(specify)______

Referral Contact: Phone- Ext. # Pager-
Referral Contact e-mail:
Alternate Contact: Phone- Ext. # Pager-

Program Requested:St. Peter’s Hospital - Rehabilitation Program(Please complete pgs. 1-3)

St. Joseph’s Hospital – Slow Reactivation Service(Please complete pgs. 1-4)

Note: Applicants may be considered for both the Rehabilitation Program at St. Peter’s Hospital and the Slow Reactivation Service at St. Joseph’s Hospital’s Complex Continuing Care. They will be offered the first available bed in either site, unless only one preference is stated.

FAX Referral to: (905)-549-4030

Admitting and Health Information

St. Peter’s Hospital

88 Maplewood Avenue

Hamilton, Ontario,L8M 1W9

Phone: 905-77PETES (777-3837)

ADMISSION REFERRAL DEMOGRAPHIC INFORMATION

Patient’s Personal Information

Last Name / First Name / Male 
Female 
Address / Apt. / City / Prov. / Postal Code
Home Telephone: / Present Location: / Date Admitted (dd/mm/yy)
Date of Birth (mm/dd/yy) / Age / Marital Status:  Single  Married/Partner
 Separated  Widowed  Divorced
Preferred Language: / Other Languages: / Religion:
Diagnosis:
Family Physician: / Phone: / Fax:
Consulting Physician: / Phone: / Fax:

Health Insurance Information

Is patient covered under Ontario Health Insurance Plan?  Yes  No If NO, indicate other health insurance plan: / Health Card Number:
/ / / / / / / / / / / Version
Code:

Contact Information

Next-of-Kin:
Relationship: / Power of Attorney:
 Personal Care  Financial
Address: / City: Province: Postal Code:
Telephone (home): ( ) / Telephone (work): ( ) Ext.
Primary Contact::
Relationship: / Power of Attorney:
 Personal Care  Financial
Address: / City: Province: Postal code:
Telephone (home): ( ) / Telephone (work): ( ) Ext.
Clinical Alerts
Allergies: No  Yes  Specify:
Diabetic: No  Yes  / CPR Status:  Full Code:  No Code  Not discussed:
Current Infections: MRSA: No  Yes  VRE: No  Yes  Other:

HEALTH HISTORY

Primary Diagnosis: ______

______

Date of Onset: ______

Relevant Past History:

______

______

______

REHABILITATION GOALS AND FUNCTIONAL STATUS

FIM Score: ______FIM Assessment Date: ______

Please tick in appropriate box or N/A if not applicable.

Key:I=independenceS=supervised no “hands-on” assist A=assist D=dependent on staff

PRE-MORBID STATUS
/

CURRENT STATUS

/ EXPECTED OUTCOME BASED ON PROGNOSIS
I / S / AX1 / AX2 / D / I / S / AX1 / AX2 / D / I / S / AX1 / AX2 / D
WASHING
DRESSING
FEEDING
TRANSFERS
STAIRS
AMBULATE
W/C MOBILITY
BLADDER CONT.
BOWEL CONT.
I - ADL

Pre-Morbidity Community Support Services (e.g. CCAC, DVA, etc.)______

______

______

PATIENT STATUS CONTINUED

Cognition Intact: Yes  No  (If ‘no’, MMSE result must be included:) ______

Standardized Cognitive Testing

and results, if applicable: ______

Perception Intact: Yes  No  ______

Standardized perceptual Yes  No 

Testing: Results: ______

Weight bearing status: Full  Partial  Non-WB ______

Sitting Tolerance 2-5 hrs:Yes No ______

Exit Seeking Behaviour:Yes No Describe: ______

Restraints Used: In bed: Yes  No Type: ______In Wheelchair: Yes  No Type: ______

Skin Intact: Yes  No  Location: ______Stage: ______Pressure Relief Surface: ______

Swallowing Difficulties: Yes  No ______

Communication Deficits: Yes  No ______

CVA assessment done: Yes  No  N/A  Stage arm_____ hand_____ leg_____ foot_____ postural control_____

Physiatrist/Geriatrician assessment completed: Yes  No  Enclose photocopy of assessments.

Depressive Symptoms: Yes  No  Enclose photocopy of Psychiatric/Test Results/Consults assessments completed.

Client motivated to participate in Rehab program: Yes No 

Describe extent of family support system: ______

REALISTIC Home Alone Home with Family  Retirement Home  Long Term Care 

DISCHARGE PLANS: PCS Papers Initiated: Yes  No  PCS Papers Completed and Sent: Yes  No 

Contact Therapists:O.T.______Phone No:______

(As appropriate)P.T.______Phone No:______

S.W.______Phone No:______

S.L.P.______Phone No:______

R.R.T.______Phone No:______

Form Completed By: (Print Name): ______

Signature: ______Date: ______

Prior to a decision about acceptance into the SPH Rehabilitation Program or while the client awaits admission, a member of the Rehab Team may call to clarify information.

ST. JOSEPH’S HOSPITAL CCC – SLOW REACTIVATION SERVICE

Patient Name: ______

To be considered for the Slow Reactivation Service located in the Complex Continuing Care Program at St. Joseph’s Hospital, please review and complete the following:

The Slow Reactivation Service offers a unique environment for patients to gradually work on improving their functional abilities, at a less intense pace, over a longer duration than traditional Rehabilitation Programs. St. Joseph’s Hospital has special expertise in respiratory diseases and renal diseases (dialysis treatment is available on-site) and therefore, the Slow Reactivation Service may be more suitable for these types of patients. However, any diagnosis will be considered. Patients will be assessed for acceptance for the reactivation service once deemed eligible and admitted to Complex Continuing Care.

To be eligible, applicants must:

  • Meet the criteria for admission to Complex Continuing Care
  • Be medically stable
  • Have potential to improve health, functional abilities and level of independence within a 4-12 month time frame
  • Have realistic functional goals – some applicants with a FIM score less than 40 may considered for Slow Reactivation
  • Have realistic discharge plans that may include home, LTC facility, retirement home or other supportive housing
  • Require the services of a multidisciplinary team to achieve their goals
  • Have sufficient cognitive ability to participate in goal setting, be able to learn and able to retain therapy instructions/information
  • Be willing and able to participate in the programs offered by the Slow Reactivation Service – Therapy sessions, per discipline, are initially limited to 3 times per week until consistent gains are demonstrated - The maximum number of therapy sessions, per discipline, are 1 session per day Mon-Fri

Special Treatment & Equipment Needs (check all that apply):

__IV Central Line (PICC)__Blood Transfusions__Suctioning__Isolation Room

__IV Peripheral Line__Oxygen__Communication Device__Enteral/Tube Feeds

__Dialysis__Tracheostomy__Specialty Mattress

__TPN__CPAP/BiPAP__Other (e.g.-special call bell, catheter, ostomy, etc.)

Please describe specialty needs: ______

Please attach recent Patient History/Consultation Reports and a current medication list.

Signature: ______Date: ______

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