Name
Care Home Address
Care Home Unit
(If Applicable)
Telephone number / Date of Birth
Date of admission to care home
GP: Name:
Address:
Tel:
Category of Care:
Residential □ EMI Residential □ General Nursing □ EMI Nursing □
CHC Funded □ Short term respite □ Other □ (specify below)
EMERGENCY CONTACT DETAILS
Name:
Address:
Telephone:
Relationship / Name:
Address:
Telephone:
Relationship
Documents included in this passport / Yes / No
DNAR CPR / □ / □
EHCP / □ / □
Personal Information / □ / □
Reason for Referral/Past Medical History/Baseline Function / □ / □
Body Map and Clinical Observations / □ / □
Red, Amber and Green Information / □ / □
Present Medication Information / □ / □
DoLs in place / □ / □
Documents for Discharge
Preparation for Discharge Checklist / □ / □
Discharge Medication Information / □ / □
Copy of Discharge Letter / □ / □
EDRA (Eating and Drinking at Risk of Aspiration form) / □ / □

To Care Home staff

When a resident admitted to hospital, please contact the relevant Integrated Nursing team using the numbers below to advise them of the admission

West single point 0191 5026426

North 0191 5027350

East 0191 5027424

Houghton 0191 5025763

Washington 0191 5026999

Version / Date
1 / July 2016

© Jeannie Henderson. Sunderland Clinical Commissioning Group

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Name / DoB
Past Medical History (if not already in EHCP Yes/No)
Current Presenting Problem
Normal/Baseline Function / On Day of Admission Function / On Day of Discharge Function
I / A1 / A2 / D / I / A1 / A2 / D / I / A1 / A2 / D
Chair Transfers
Bed Transfers
Mobility
Washing
Dressing
Eating/Drinking
Communication
Equipment
Cognition / Alert / Yes / No / Alert / Yes / No / Alert / Yes / No
Orientated / Yes / No / Orientated / Yes / No / Orientated / Yes / No
CHC Funding in place / Yes/No / Any Change to CHC funding Yes/No
Signed: / Sign:
Date: / Date:

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My CARE PASSPORT

Observation Chart and Body Map

Name
Date

Observations/NEWS
Baseline / Observations/NEWS
On Admission / Observations/NEWS
On Discharge
Blood Pressure
Pulse
Temperature
Respiratory Rate
Oxygen Saturations
Supplemental Oxygen
AVPU
NEWS Score

My name is

I like to be known as

/ How I Communicate:
/ Sensory Impairment:
/ Mobility/Moving Around:
/ Continence:
/ Personal Care:
/ Sleeping Pattern:
/ Special Diet/Dietary Needs/Help I need to eat:
/ Pain e.g. how you know I’m in pain:

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