CCAC IN HOME/COMMUNITY REFERRAL - Request for Assessment & Medical Treatment Orders

Transcription

1 CCAC IN HOME/COMMUNITY REFERRAL - Request for Assessment & Medical Treatment Orders CONTENTS CLIENT DETAILS & DEMOGRAPHICS... 2 REQUEST FOR ASSESSMENT... 3 MEDICAL TREATMENT ORDERS (PAGE 1 of 2)... 4 MEDICAL TREATMENT ORDERS (PAGE 2 of 2)... 5 PHYSICIAN/NP SIGN-OFF P a g e

2 CLIENT DETAILS & DEMOGRAPHICS DATE COMPLETED M M D D Y Y Y Y / / CLIENT DETAILS & DEMOGRAPHICS Date of Birth M M D D Y Y Y Y / / Health Card Number Health Card Version Code Health Card Expiry Date MRN M M D D Y Y Y Y / / CCAC IN HOME/COMMUNITY REFERRAL DOWNTIME FORM Address Number and Street City/Town Province Postal Code Phone Number ( ) - Current Location Site & Unit/Clinic: IS THERE AN ALTERNATE CONTACT FOR PATIENT? Yes Phone ( ) - Relationship: No IS THE TREATMENT ADDRESS DIFFERENT THAN THE HOME ADDRESS? Yes Number and Street City/Town Province ON Phone ( ) - No Postal Code IS AN INTERPRETER REQUIRED? Yes Language(s) requested: _ No REFERRAL OWNER Phone Number ( ) - ext. Pager Number ( ) - ALTERNATE STAFF CONTACT (IF APPLICABLE) Role Contact/Unit Phone Number ( ) - ext. 2 P a g e

3 REQUEST FOR ASSESSMENT PRIMARY DIAGNOSES/RELEVANT MEDICAL HISTORY AND REASON FOR REFERRAL CCAC IN HOME/COMMUNITY REFERRAL DOWNTIME FORM PRECAUTIONS/RISK (IF APPLICABLE) To patient and/or provider Behaviours Falls Infection Control Infestation(s) Other, specify Please specify precautions/risks details: IS A MEDICAL TREATMENT ORDER REQUIRED? (such as: Enteral Feeding, Medication(s)/Hydration, Peritoneal Dialysis, Tube/Drain Care, Urinary Catheter Care, Vascular Access Device Care, Wound Care/Dressing) Yes - Complete the Medical Treatment Orders form and Allergies below No To be determined Allergy Information (For example: medication, latex, tape allergies, or no known allergies (NKA)): SERVICES REQUESTED Please select all that apply and complete the associated discipline-specific reports Case Management no associated report Dietitian Home First no associated report Nursing (Select only when Physician sign-off not required, excluding wound care/dressing) Occupational Therapy Palliative Care: If client resides in Toronto, please complete and submit Common Palliative Care Referral Form. Prognosis (e.g. less than 3 months) Palliative Performance Scale (%) Personal Support Worker no associated report Pharmacy no associated report Physiotherapy Speech Language Pathology Social Work Other Services Requested, please specify: EXPECTED DISCHARGE DATE (IF APPLICABLE) Date (MM/DD/YYYY) / / OTHER RELEVANT INFORMATION COMPLETED BY: I have completed this form and reviewed required information Role Contact/Unit Phone Number ( ) - ext. Date (MM/DD/YYYY) / / 3 P a g e

4 CCAC IN HOME/COMMUNITY REFERRAL DOWNTIME FORM MEDICAL TREATMENT ORDERS (PAGE 1 of 2) WOUND CARE Please specify wound description (type, location, depth, stage/category if applicable), dressing order (cleansing, type of dressing, frequency, packing if required, last dressing change) For VAC wound, please specify type of pressure (continued/intermittent), amount of pressure, change frequency, white/black foam MEDICATION(S)/HYDRATION Foe each medication, please specify drug, dose, route, frequency, duration, when was/will last dose be given in hospital (date, MM/DD/YY and time), next dose due (date, MM/DD/YY and time). If applicable, please specify VAD flushing/locking information: VASCULAR ACCESS DEVICE CARE (e.g. CVAD/PIV) WITH NO ADDITIONAL MEDICATION/HYDRATION Please specify type of line, solution, and any additional VAD dressing information: TUBE/DRAIN CARE Please specify type, location, insertion date, specific care orders, maximum fluid removal, flushing and site dressing change, parameters for drain removal: 4 P a g e

5 CCAC IN HOME/COMMUNITY REFERRAL DOWNTIME FORM MEDICAL TREATMENT ORDERS (PAGE 2 of 2) URINARY CATHETER CARE Please specify type of urinary catheter, size, frequency of catheterization/changes, date of insertion (MM/DD/YY), flushing order (solution, amount, frequency of catheterization): PERITONEAL DIALYSIS Please specify type, baseline assessment data, dialysis order (continuous ambulatory peritoneal dialysis (CAPD), automated peritoneal dialysis (APD), exit site care) and all special instructions: ENTERAL FEEDING ORDER AND FLUSHING Please specify type of tube, pump or gravity, continuous vs. intermittent, formula type, volume, rate (ml/hr or number of cans/set times), frequency, duration, flushing amount and flushing frequency: OTHER MEDICAL TREATMENT BEING ORDERED Please specify details: COMPLETED BY: I have completed this form and reviewed required information Role Contact/Unit Phone Number ( ) - ext. Date (MM/DD/YYYY) / / 5 P a g e

6 CCAC IN HOME/COMMUNITY REFERRAL DOWNTIME FORM PHYSICIAN/NP SIGN-OFF Attending Physician I approve of the medical treatment orders contained herein to be performed Attending Physician Information Resident/Fellow - I authorize the medical treatment orders contained herein on behalf of attending physician Physician Delegate Information (Specify Attending Physician Information Below) Role/Specialty Nurse Practitioner or Registered Nurse (Extended Class) -I approve of the medical treatment orders contained herein to be performed Nurse Practitioner or Registered Nurse Information Role/Specialty Chiropodist - I approve of the medical treatment orders contained herein to be performed Chiropodist Information Midwife - I approve of the medical treatment orders contained herein to be performed Midwife Information Attending Physician Information (If applicable) Completed On: Date (MM/DD/YYYY) / / 6 P a g e