Specialist Assessment Form - Adult (SAF) To be completed within 24 hours of admission

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1 Specialist Assessment Form - Adult (SAF) To be completed within 24 hours of admission Patient s name: DOB: Ward: Unit No: NHS No: Gender: M/F Name of person completing this form: Designation: Date Completed: Names of others who helped complete this form: Does the patient hold a health access card/health action plan YES NO If answer is yes where is the health access card/health action plan Guidance form completion of Specialist Assessment Form This form is divided into six sections and is intended to aid and support caring for a patient who has learning disabilities. Should take no more than 10 min to complete. SECTION ONE Completed by the patient s carers/families in relation to the adult s needs, or staff feel it is appropriate and would support the patients care plan. SECTION TWO - Completed by patients who feel able to express their own needs effectively, and staff feel it is appropriate. SECTION THREE Review of Form SECTION FOUR Risk screening tool for additional staffing SECTION FIVE Discharge flow chart SECTION SIX - Pain management chart 1

2 SECTION ONE This form should be completed with the patient and their family member or carers. It is designed to give staff vital information about the patient and the care needed if their family members/carers are unavailable. Pen Picture only requires a few sentences about the person with learning disability. At the end of Section One there is a space for any additional information that may be useful when ensuring all reasonable adjustment is being made to support and care for the patient. Pen Picture descriptions, (including things that will help the person with learning disabilities feel better) for: How does He/She look when they are well? How does He/She look when they are ill? How does He/She sound when they are well? How does He/She sound when they are ill? 2

3 What is His/Her normal routine? What are His/Her actions when they are ill? What is He/She like when they are in pain or there are signs of pain increasing? What helps to reduce their pain? Does He/She have any behavioural problems? Is there a behavioural plan? 3

4 Does He/She have any known triggers of distress or signs of distress increasing? Are there any actions which can be taken to manage the situation more effectively? How does He/She communicate? Dietary needs, including equipment, and if on textured diet type. If peg, ensure detailed regime 4

5 Please state briefly, any other information including likes and dislikes 5

6 SECTION TWO Completed by patients who feel able to express their own needs effectively, the rest of the form does not need to be completed. Patient s signature: Date: I have discussed with the patient how they express pain, anxiety and communicate their needs and wishes. Signed by : Date: Designation: Additional information given by patient: 6

7 SECTION TWO REVIEW OF SPECIALIST FORM Inter-ward transfer Check with carer and initial Reviewed Staff:.. Reviewed Carer:. Date: Re admission after 24 hours with same condition Check with carer and initial Reviewed Staff:.. Reviewed Carer:. Date: Re admission after 48 hrs with same condition Check with carer and initial Reviewed Staff:.. Reviewed Carer:. Date: Re admission within 7 days with same condition Check with carer and initial Reviewed Staff. Reviewed Carer Date: 7

8 SECTION FOUR RISK ASSESSMENT To be completed for all patient SECTION FIVE Other Professional involved to enable staff to contact other professional if further advise or at point of discharge SECTION SIX Pain management chart SECTION SEVEN- My discharge leaflet 8

9 SECTION 4 - Rapid Risk Assessment for patients with Learning Disabilities and/or Autism Patient detail: Assessment criteria Personal safety No issues identified Score Requires regular observation and reinforcement to maintain safety. 1 0 Level of learning or physical disability requires half hourly checks to maintain safety. Mental health status affects ability to maintain safety. Additional sensory disability. blind or deaf. 2 Unable to maintain own safety due to level of learning disability/autism, may wander, remove medical devices e.g. cannulas, drains. Complex physical disabilities require continuous observation and management of posture to maintain airway. High risk of pressure area breakdown (Waterlow). High risk of falls (falls assessment). Safeguarding issue identified. 3 Swallowing, Nutrition, hydration No previous or current history of swallowing issues. Previous history of swallowing issues but has not been formally assessed. Requires support to ensure adequate food and fluid intake. 0 1 Requires safe positioning or additional support for eating/drinking/non oral feeding. Long term feeding via a peg or NGT and is NBM. History of recurrent chest infections or unintentional weight loss. 2 Assessment indicates high risk of Dysphagia. 3 9

10 Assessment criteria Score On modified food/thickened fluids. Requires one to one support whist eating/drinking for safe swallowing. Communication Good verbal communication and understanding. Indicates when/where has pain. 0 Some verbal communication uses non verbal systems to supplement. Requires additional time to process information and respond. Uses some non verbal signs, facial expressions, body language or behaviour to communicate. Requires extra time and /or information in alternative formats. 1 2 Extremely limited communication Requires support from carers to interpret need. 3 Mental capacity Assessment indicates no capacity issues. Can make own decisions and/or consent to treatment with clear explanation Understands simplified explanation of procedures Requires reinforcement, extra time, accessible information to support decision making. 0 1 Has difficulties understanding complex treatments/ interventions but will consent with reinforcement and support. 2 Is unable to understand, retain, weigh up, communicate back and make decisions related to treatment/interventions (lacks capacity). Very unlikely to comply with treatment/interventions. 3 Epilepsy No known seizure activity. 0 Seizures well controlled by medication or infrequent. 1 Poorly controlled or unpredictable seizures. Seizure activity increased by illness or anxiety. 2 Seizure activity is prolonged or difficult to recognise leading to loss of consciousness. High risk of airway obstruction or aspiration during seizures 3 (history). Behaviours and No issues identified. 0 10

11 Anxieties Assessment criteria May become anxious in new environments, needs reassurance and extra time to reduce anxiety. May display inappropriate behaviour, needs clear boundaries and reinforcement. Score 1 Regularly displays inappropriate behaviours e.g. stripping. Sometimes displays aggressive behaviours. 2 Severe hospital phobia or unable to wait. Regularly displays aggressive behaviours to self or others, high risk of injury. Requires own carers to manage needs. Total: Part 2 overleaf must be completed 3 11

12 Patient detail: Score = 0-8 low risk Score = 9-12 Medium risk Score = High risk Low risk Care Bundles Complete all Trust risk assessments i.e. Falls, Waterlow, MUST. Implement basic nursing care monitoring charts e.g. fluid charts, food charts, epilepsy charts. Refer to Trust learning disabilities policies Nursing Policies and Guidelines folder on the Trust Intranet; Disabilities folder or liaise with link practitioner for further advice. Liaise with carers to identify usual support and communication needs. Check if known to specialist learning disability team. Ensure LD code added to PAS (with consent) Document decisions in relation to patients mental capacity Is the person able to? Understand the information relative to the decision Retain information long enough to make the decision Use or weigh up the information to make the decision Communicate the decision back by appropriate means Medium risk - as above plus: Increase level of supervision and observation. Confirm level of support that can be offered by carers, document on care plan. Consider increased support needs. Use Trust one to one policy. Use alternative methods to assess potential clinical issue Make referrals to appropriate health care professionals e.g. SALT, Physiotherapist, Dietitian etc. Involve specialist learning disability team High risk - as above plus: Tick on completion Tick on completion Tick on completion Signature Signature Signature Agree additional support needs with senior nurse, either via internal bank or from specific homes Make referral to Acute Liaison Nurse for advice and support Ensure principles of the Mental Capacity Act are followed in relation to best interest and consent. Arrange MDT meeting to support safe discharge planning and continuing care needs. DOCUMENT ALL ACTIONS CLEARLY IN THE PATIENT S HEALTHCARE RECORDS 12

13 SECTION FIVE Additional professionals - to aid for MDT e.g Community Consultant,, Physio, OT Learning Disability Nurse Advisors Other professional/agencies involved in His/Her care: 13

14 SECTION SIX 14

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