London specialist inpatient rehabilitation referral & assessment form
(Version 3: September 2008)
1. Patient informationPatient’s name: ………………………………… Date of birth: ……… Age: …….. Gender: ………
NHS no.: ………………………………………... Name of the Primary Care Trust
responsible for the patient’s care: ………………………
Home address: ………………………………… Tel: …………………
………………………………… Post code: …………
Patient’s present whereabouts:
An inpatient on ………………… Ward at …………………..Hospital Tel: ……………….. Fax ……………….
Address of hospital ……………………………………………
…………………………………………….
At home at the above address
Other (please specify) ………………………………………..
2. Consultant/Referrer information
Name: …………………………………
Address: ………………………………
……………………………….
Tel: …………………………………….
Fax: …………………………………… / 3. General Practitioner details
Name: …………………………………
Address: ………………………………
……………………………….
Tel: …………………………………..
……………………………………
Fax: ………………………………….
4. Referring Medical Practitioner/Consultant
If following a period of rehabilitation at the specialist neurological rehabiliation units, this patient is unable for any medical or social reasons to return home/into a suitable placement –
I agree to readmit him to this hospital/ to a bed at ………………………………… (delete as appropriate)
Signature …………………………………………….Title ………………………………………………….
Name (please print) …………………………………Date …………………………………………………
5. Diagnosis
Primary diagnosis: ……………………………………………………………Date of onset: …………………......
Date of surgery (if applicable): ………………………………………………………………………………………
Surgical procedure: …………………………………………………………………………………………………...
Secondary diagnoses: ………………………………………………………………………………………………..
………………………………………………………………………………………………..
6. Reasons for referral
Intensive inpatient multidisciplinary rehabilitation
Disability management:
Advice for appropriate placement:
Other:
If other, please specify.…………………………………………………………………………………………......
………………………………………………………………………………………………
7. Summary of medical/surgical history
Drug/alcohol use: ……………………………………………………………………………………………………..
History of deliberate self harm: ……………………………………………………………………………………...
Previous physical & cognitive function…………………………………………………………………………..
…………………………………………………………………………..
8. Investigations
YesNoIf yes, DateComments/Further details
CT scan:……………….
MRI:……………….
Other:……………….
If the patient has had a stroke, please complete the following:
YesNoIf yes, DateComments/Further details
Echocardiogram:……………….
Carotid doppler/duplex:……………….
ESR:……………….
Auto-antibody screen:……………….
Other:……………….
9. Current medication
1. ……………………………………………………… 4. …………………………………………………………….
2. ……………………………………………………... 5. …………………………………………………………….
3. ……………………………………………………… 6. …………………………………………………………….
10. Any additional medical/surgical information
11. Summary of disabilities
YesNoComments/Further details
Altered state of awareness:
Cognitive/communicative problems:
Behavioural problems:
Physical deficits:
Higher respiratory needs:
12. Mobility and transfers
Transfers (Tick 1)Mobility
IndependentWalkingWheelchair
Assistance from 1IndependentN/A
Assistance from 2Supervision/help from 1Pushed in a wheelchair
HoistSupervision/help from 2Independent
BedboundHas own chair Yes/No
If yes, is it suitableYes/No
Risk of fallsYesNo
13. Vision and hearing
YesNoComments/Further details
Visual problems:
Hearing problems:
14. Cognition and communication
Level of communication (please circle as appropriate)
Consistent yes/no responsesSingle word levelSentences Full phrases
YesNoComments/Further details
Cognitive problems:
Perceptual problems:
Ability to learn:
Other:
Dysphasia:
Expressive dysphasia:
Receptive dysphasia:
Dysarthria:
Other:
Capacity to consent:…………………………………………………………………………..
If no, Has Deprivation of Liberty Safeguards been undertaken including involvement of Independent Mental Capacity Advocate?......
15. Behavioural problems
YesNoComments/Further details
Agitation:
Wandering/absconding:
Self harm:
Verbal aggression:
Physical aggression:
One to one supervision:
YesNo
Is the patient under a mental health act detention order?
Comments/Further details
16. Any additional information on patient’s current level of disabilities
17. Nurisng information
YesNoComments:
Dysphagia:
Oral feeding:
Nasogastric feeding:
PEG feeding:
Pressure sores:
Special mattress:
Other special
nursing requirements:
Urinary incontinence:If yes, occasionalregular
Urinary catheter:
Faecal incontinence:If yes, occasionalregular
MRSA:If yes, colonisationinfection
C difficile
Tracheostomy:If yes,cuffeduncuffed
weaning programmestabilised
18. Social situation
Occupation: ……………………………………. Marital status: ……..
Next of kin information: ………………………………………. Contact details …………………………………...
Other contact information (Optional) ……………………….. Contact details …………………………………...
Relative or professional involved in patient’s care
Comments/Further details
Lives alone
Lives with:
Parents
Husband/wife/partner
OtherPlease specify: ………………………………………………………………….
19. Type of residence and accessibility
Comments/Further details
Owner/occupied:
Council/housing association:
No fixed abode:
Other:Please specify: ………………………………………………………..
20. Current rehabilitation input
YesNoComments:
Physiotherapy:
Occupational Therapy:
Speech & Language Therapy:
Psychology:
Dietetics:
Social Worker:
Please attach reports from the therapists currently involved in the care of the patient, or arranged for them to be sent.
21. Goals for rehabilitation
YesNo
Primarily cognitive/communicative and behavioural
Primarily complex physical
Additional comments:
22. This referral is for consideration of the following service(s)
1. Blackheath Brain Injury Rehabilitation Centre6. Regional Neurological Rehabilitation Unit
1.1. The Thames Brain Injury Rehabilitation Unit HomertonHospital
1.2. The Heathside Neurodisability Unit
2. Edgware Brain Injury Rehabilitation Unit7. Regional Rehabilitation Unit NorthwickParkHospital
3. Frank Cooksey Rehabilitation Unit8. RoyalHospital for Neurodisability
King’s CollegeHospital Putney
4. Lishman Brain Injury Unit9. Wolfson Neuro-rehabilitation Centre
MaudsleyHospital
5. Neuro-rehabilitation Unit, NationalHospital
for Neurology & Neruosurgery
Reasons for chosing the service(s)
Particular specialist expertise:
Family preference:
Other:
If other, please specify …………………………….
Additional comments
This section is to be filled in by the assessor(s)
This assessment was undertaken by ………………………………………………………………………………
from the ……………………………………………………………………………….. specialist rehabilitation unit
Unidisciplinary assessmentMultidisciplinary assessment
Assessment undertaken at the
Referring hospital/unitSpecialist rehabilitation unit
HomeOther
If other, please indicate …………………………...
Date of assesssment: ………………………………….
Summary and recommendations
Suitable for the following units 1 …………………………………..
2 …………………………………..
3 …………………………………..
The paitent is suitable for specialist inpatient rehabilitationYesNo
If yes, this patient is for
Primarily complex physical rehabilitation programme
Cognitive/communicative and/or behavioural rehabilitation programme
If no, please give the reasons and alternative recommendations:
Patient fit for transfer for rehabilitationYesNo
Patientrequires reassessmentYesNo
If yes, reasons for re-assessment
Signature …………………………………………….Title ………………………………………………….
Name of the assessor (please print) ……………………Date …………………………………………………
Contact telephone no. (mobile) ……………………………………………………………………………………...
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