FRANK COOKSEY REHABILITATION UNIT (FCRU) ORPINGTON HOSPITAL EMAIL

FRANK COOKSEY REHABILITATION UNIT (FCRU) ORPINGTON HOSPITAL EMAIL
10 GEOTAILCPI PUBLICATIONS L A FRANK ET AL DEPARTMENT
10 VOM ALPINEN FÜRSTENTUM ZUM KÖNIGREICH VON FRANKREICH DER

120814 MAYOR FRANK EWERT CALLED THE REGULAR MEETING OF
18 POLARVIS PRESENTATIONS L A FRANK ET AL DEPARTMENT
18 ST STEPHENS EPISCOPAL PROCATHEDRAL 35 S FRANKLIN STREET

London specialist inpatient rehabilitation referral form

FRANK COOKSEY REHABILITATION UNIT (FCRU) ORPINGTON HOSPITAL EMAIL

Frank Cooksey Rehabilitation Unit (FCRU), Orpington Hospital
Email: [email protected] Tel: 01689 866380

London specialist inpatient rehabilitation referral & assessment form

1. Patient information


Patient’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 rehabilitation 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 …………………………………………………


Ethnic Origin: Please indicate to which ethnic group your patient belongs:


ASIAN

ANY OTHER BACKGROUND


ASIAN

BANGLADESHI


ASIAN

INDIAN


ASIAN

PAKISTANI


BLACK

AFRICAN


BLACK

ANY OTHER BACKGROUND


BLACK

CARIBBEAN


MIXED

ANY OTHER BACKGROUND


MIXED

WHITE & ASIAN


MIXED

WHITE & BLACK AFRICAN


MIXED

WHITE & BLACK CARIBBEAN


OTHER

ANY OTHER


OTHER

CHINESE


WHITE

ANY OTHER BACKGROUND


WHITE

BRITISH


WHITE

IRISH




WHY WE RECORD PATIENTS’ ETHNIC ORIGIN:


We serve a multi-ethnic and multi-cultural population. The recording of patients’ ethnic group is necessary for the following reasons:


  • To identify who is currently using our services and whether those services are accessible to people from different ethnic groups.


  • To check whether any particular groups are over or under-represented within any part of the service.


  • To help identify patterns of illness and need amongst different ethnic groups.


  • To stimulate and guide staff awareness of and response to the varied customs, beliefs and needs of different ethnic groups.



WHO HAS ACCESS TO THIS INFORMATION:


Information on an individual’s ethnic group is STRICTLY CONFIDENTIAL, as are all other patient details.


Access to all patient information will be restricted to staff involved in the patient’s direct care.




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


Yes No If yes, Date Comments/Further details

CT scan: ……………….

MRI: ……………….

Other: ……………….


If the patient has had a stroke, please complete the following:


Yes No If yes, Date Comments/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


Yes No Comments/Further details

Altered state of awareness:

Cognitive/communicative problems:

Behavioural problems:

Physical deficits:

Higher respiratory needs:



12. Mobility and transfers


Transfers (Tick 1) Mobility

Independent Walking Wheelchair

Assistance from 1 Independent N/A

Assistance from 2 Supervision/help from 1 Pushed in a wheelchair

Hoist Supervision/help from 2 Independent

Bedbound Has own chair Yes/No

If yes, is it suitable Yes/No

Risk of falls Yes No

13. Vision and hearing


Yes No Comments/Further details

Visual problems:

Hearing problems:



14. Cognition and communication


Level of communication (please circle as appropriate)


Consistent yes/no responses Single word level Sentences Full phrases


Yes No Comments/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

Yes No Comments/Further details

Agitation:

Wandering/absconding:

Self harm:

Verbal aggression:

Physical aggression:

One to one supervision:


Yes No

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. Nursing information


Yes No Comments:

Dysphagia:

Oral feeding:

Nasogastric feeding:

PEG feeding:


Pressure sores:

Special mattress:

Other special

nursing requirements:


Urinary incontinence: If yes, occasional regular

Urinary catheter:

Faecal incontinence: If yes, occasional regular

MRSA: If yes, colonisation infection

C difficile

Tracheostomy: If yes, cuffed uncuffed

weaning programme stabilised

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

Other Please 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


Yes No Comments:

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 arrange for them to be sent.



21. Goals for rehabilitation

Yes No

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 Centre 6. Regional Neurological Rehabilitation Unit

1.1. The Thames Brain Injury Rehabilitation Unit Homerton Hospital

1.2. The Heathside Neurodisability Unit

2. Edgware Brain Injury Rehabilitation Unit 7. Regional Rehabilitation Unit Northwick Park Hospital


3. Frank Cooksey Rehabilitation Unit 8. Royal Hospital for Neurodisability

King’s College Hospital Putney


4. Lishman Brain Injury Unit 9. Wolfson Neuro-rehabilitation Centre

Maudsley Hospital


5. Neuro-rehabilitation Unit, National Hospital

for Neurology & Neurosurgery


Reasons for choosing 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 assessment Multidisciplinary assessment


Assessment undertaken at the

Referring hospital/unit Specialist rehabilitation unit

Home Other

If other, please indicate …………………………...

Date of assessment: ………………………………….


Summary and recommendations

Suitable for the following units 1 …………………………………..

2 …………………………………..

3 …………………………………..


The patient is suitable for specialist inpatient rehabilitation Yes No


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 rehabilitation Yes No

Patient requires reassessment Yes No


If yes, reasons for re-assessment






Signature ……………………………………………. Title ………………………………………………….


Name of the assessor (please print) …………………… Date …………………………………………………


Contact telephone no. (mobile) ……………………………………………………………………………………...


9

V5 – Jan 2016


193 FRANKLIN D ROOSEVELT AND THE SHADOW OF WAR
1960 2ND JANUARY GEORGE ANDERSON [OR] TRANENTALLOA ATHLETIC FRANK
2 AUFLAGE FRANK KEMPKEN UNIVERSITÄT KIEL RENATE KEMPKEN GENTECHNIK


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