MAPLES /PHOENIX REHABILITATION REFERRAL REFERRAL DETAILS:

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1 MAPLES /PHOENIX REHABILITATION REFERRAL Each section must be completed by the treating health professional and goals for rehabilitation must be indicated. Once completed, please post the referral form to Una Goulding at the Maples Unit, The Royal Hospital Donnybrook, Morehampton Road, Donnybrook, Dublin 4. Only patients who meet the admission criteria will be accepted to the Rehabilitation Unit. Please do not organise patient transfer until the Nurse Manager has confirmed that the patient has been accepted for rehabilitation, and has confirmed bed availability. Need more information? Please contact us on (01) or (01) REFERRAL DETAILS: Referring Hospital / Facility: Referral Date / / Ward / Area: Contact Person: Contact Phone No: Fax No: This section is for the RHD Rehabilitation Team s use only. Please place referral receipt stamp here

2 NURSING CONSIDERATIONS Next of Kin /Contact: Relationship: Address / Phone: Has patient/family consented to Rehab: Yes / No Known Allergies (specify) Intake (specify): Oral / NGT / PEG Diet: Fluids: State of consciousness: Supplements: Alert Lethargy / Fatigue Aids / prosthesis (specify): Confusion / Dementia Does the patient have a history of wandering/exit seeking behaviour : Specific equipment needs: Skin integrity / wounds: Communication: Visual impairment Yes / No (specify): Dressing / Treatments: Hearing impairments Yes / No (specify): Elimination: Speech impairment Yes / No (specify): Bladder: Continent/Incontinent/IDC/SPC Bowels: Continent / Incontinent Other sensory impairment Yes / No (specify): Infection: Yes / No (specify): Mobility (specify): Current MRSA Status: Swabs taken: Yes / No Does the patient have a history of falls: Date: Hygiene needs (specify): Results: Detected / Not Detected Sites Detected: Additional Comments / Specific Management Problems: Referring Nurse: Contact Phone: Date: MEDICAL SUMMARY

3 Age: Date of Admission to Referring Facility / / Diagnosis: PRE ADMISSION STATUS: Please include considerations such as medical and social history, family support, mobility and ADL status of patient prior to admission. Indicate information relevant to discharge planning including any perceived difficulties: CURRENT STATUS: Please include considerations such as principle diagnosis, allergies, current medical problems requiring active treatment, current medications and any alterations to medications made during this admission, relevant diagnostic radiology or pathology, MMSE, cognitive assessments or Neuro. Psych. Assessment, if attended. Consultant: Referring Medical Officer: Contact Phone / Pager No.: Date:

4 PHYSIOTHERAPY ASSESSMENT Please include considerations such as Physiotherapy interventions and treatment goals to date, other factors impacting on treatment (including cognitive, emotional and motivational state), transfers (level of assistance required and equipment requirements including hoist type), mobility, gait, sitting balance and any other relevant comments. Referring Physiotherapist:

5 OCCUPATIONAL THERAPY ASSESSMENT Please include considerations such as cognitive assessments PTA Score, and include comments about the patients memory, attention, concentration, visual perception, appropriateness of interaction, level of dependence with ADLs, splinting requirements and any other relevant comments. Referring Occupational Therapist:

6 SPEECH THERAPY ASSESSMENT Please include information on swallowing assessment, diet requirements, meal management strategies, communication status and any other information relevant to management. Referring Speech Pathologist:

7 DIETITIAN ASSESSMENT Please include information on anthropometry, dietary requirements, nutrition interventions and any other information relevant to management. Referring Dietician

8 SOCIAL WORKER ASSESSMENT Please include considerations such as the client s social history, and relevant issues such as, family relationship matters. Also record housing, transport, financial and substance issues the client may have, which could affect a positive outcome for the client during their stay on the Rehabilitation Unit. Referring Social Worker:

9 PSYCHOLOGY ASSESSMENT Please note any psychological assessment or intervention that has been offered to the patient, with regard to adjustment, emotional or behaviour difficulties, including neuropsychological assessment. As Psychology is a limited and referral-based resource within The Royal Hospital Donnybrook, it would be very helpful to indicate whether an immediate Psychology referral is likely to be required to continue any previous input. Please forward any relevant reports, including strategies or recommendations, separately if appropriate and contact the Clinical Psychologist ( ) if required. Referring Psychologist:

10 REFERRAL REVIEW RECOMMENDATIONS This section to be completed by The Royal Hospital Donnybrook. Date referral received: / / Date referral reviewed by team: / / Referral Source Diagnosis: Patient meets Rehabilitation Admission Criteria: Yes / No Case Coordinator: Team Recommendations (including notification of bed availability): Signed: Name: Date: On behalf of the Rehab Team, RHD. Nurse Manager notified of team recommendations: Yes / No Date: / / By whom: Referring Hospital / Facility notified of team recommendations: Yes / No Date: / / By Phone Fax By whom:

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