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CCAC IN HOME/COMMUNITY REFERRAL

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 ......................................................................................................................................................... 6

DIETITIAN REPORT .................................................................................................................................................................. 7

NURSING REPORT ................................................................................................................................................................... 8

OCCUPATIONAL THERAPY REPORT ......................................................................................................................................... 9

PHYSIOTHERAPY REPORT (PAGE 1 of 2) ................................................................................................................................ 10

PHYSIOTHERAPY REPORT (PAGE 2 of 2) ................................................................................................................................ 11

SPEECH LANGUAGE PATHOLOGY REPORT (PAGE 1 of 2) ...................................................................................................... 12

SPEECH LANGUAGE PATHOLOGY REPORT (PAGE 2 of 2) ...................................................................................................... 13

SOCIAL WORK REPORT .......................................................................................................................................................... 14

CCAC IN HOME/COMMUNITY REFERRAL DOWNTIME FORM

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CLIENT DETAILS & DEMOGRAPHICS DATE COMPLETED M M D D Y Y Y Y __ __ / __ __ / __ __ __ __

CLIENT DETAILS & DEMOGRAPHICS

Name Last Name ______________________________________

First Name ______________________________________

Date of Birth M M D D Y Y Y Y __ __ / __ __ / __ __ __ __

Health Card

Number __ __ __ __ __ __ __ __ __ __ Health Card Version Code Health Card Expiry Date

M M D D Y Y Y Y __ __ / __ __ / __ __ __ __

MRN

Address Number and Street City/Town Province Postal Code

Phone Number ( ) ____ - ______ Current Location Site & Unit/Clinic:

IS THERE AN ALTERNATE CONTACT FOR PATIENT?

□ Yes Last Name _________________________________________

First Name _____________________________________________

Phone ( ) ____ - ______ Relationship: _________________________________ □ No

IS THE TREATMENT ADDRESS DIFFERENT THAN THE HOME ADDRESS?

□ Yes Number and Street City/Town Province ON

Postal Code

Phone ( ) ____ - ______ □ No

IS AN INTERPRETER REQUIRED?

□ Yes Language(s) requested: _______________________________________________________________□ No

REFERRAL OWNER

Name Last Name ______________________________________

First Name ______________________________________

Phone Number ( ) ____ - ______ ext. _____ Pager Number ( ) ____ - ______

ALTERNATE STAFF CONTACT (IF APPLICABLE)

Last Name ________________________________________________

First Name _______________________________________________

Role ________________________________________________

Contact/Unit Phone Number( ) ____ - ______ ext. ____


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REQUEST FOR ASSESSMENT PRIMARY DIAGNOSES/RELEVANT MEDICAL HISTORY AND REASON FOR REFERRAL

PRECAUTIONS/RISK (IF APPLICABLE) – To patient and/or provider

□ Behaviours □ Falls □ Infection Control □ Infestation(s) □Other, specifyPlease 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 (p.4-6) □ 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 mandatory associated discipline-specific reports

□ Case Management – no associated report□ Dietitian (p.7)□ Home First – no associated report□ Nursing (p.8)□ Occupational Therapy (p.9)□ 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 (p.10)□ Speech Language Pathology (p.12)□ Social Work (p.14)□ 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

Last Name _______________________________

First Name _______________________________

Role _______________________________

Contact/Unit Phone Number ( ) ____ - ______ ext. _____ Date (MM/DD/YYYY) __ __ / __ __ / __ __ __ __

Last Name: ________________________ First Name:________________________ HCN:_________________


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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/NPWT 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:



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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:


Last Name _______________________________

First Name _______________________________

Role _______________________________




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PHYSICIAN/NP SIGN-OFF □ Attending Physician – I approve of the medical treatment orders contained herein to be performed

Attending Physician Information

Name Last Name ___________________________________

First Name ___________________________________

□ Resident/Fellow - I authorize the medical treatment orders contained herein on behalf of attending physicianPhysician Delegate Information (Specify Attending Physician Information Below)

Name Last Name ___________________________________

First Name ___________________________________

Role/Specialty

□ Nurse Practitioner or Registered Nurse (Extended Class) -I approve of the medical treatment orders contained

herein to be performedNurse Practitioner or Registered Nurse Information

Name Last Name ___________________________________

First Name ___________________________________

Role/Specialty

□ Chiropodist - I approve of the medical treatment orders contained herein to be performedChiropodist Information

Name Last Name _______________________________

First Name _______________________________

□ Midwife - I approve of the medical treatment orders contained herein to be performedMidwife Information

Name Last Name _______________________________

First Name _______________________________

Attending Physician Information (If applicable) Name Last Name

_______________________________First Name _______________________________

Completed On:

Date (MM/DD/YYYY) __ __ / __ __ / __ __ __ __



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DIETITIAN REPORT NUTRITIONAL HISTORY For example: height, weight, BMI, food allergy, and special diet

REASON FOR NUTRITION INTERVENTION

GOAL OF NUTRITION CARE Please select all that apply:

□ Optimize macro/micronutrient intake

□ Maintain nutritional status

□ Replete nutritional status

□ Other, specify: __________________________________________________________________________________

Goal of nutrition care details:

ENTERAL FEED Indicate tolerance of feeds, digestion, teaching, support, monitoring requested

DIETITIAN COMMENTS


Last Name _______________________________

First Name _______________________________

Role _______________________________




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NURSING REPORT AREAS FOR RN INTERVENTION (Orders above the dermis that do not require Physician sign off) For example: respiratory or cardiac management, diabetic education, and medication compliance

COMPLETED BY: I have completed this form and reviewed required information Last Name _______________________________

First Name _______________________________

Role _______________________________




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OCCUPATIONAL THERAPY REPORT CURRENT FUNCTIONAL STATUS AND REASON FOR REFERRAL Indicate cognitive status, aids used/required/recommended, ambulatory status, safety recommendations, kitchen/bathroom assessment done

SUGGESTED COMMUNITY GOALS Indicate what problems are foreseen upon discharge

Immediate:

Long Term:

COMMENTSIndicate attitude, motivation, social issues, family contact, complicating medical issues, resources


Last Name _______________________________

First Name _______________________________

Role _______________________________




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PHYSIOTHERAPY REPORT (PAGE 1 of 2) SURGICAL PROCEDURE/INTERVENTION Include type, date, contraindications and restrictions

RELEVANT HISTORY

PHYSIOTHERAPY IN HOSPITAL Brief outline of treatment and current status (include date initiated and frequency)

CLIENT LIVES Please select one of the following:

□Alone □With family/othersSpecify details:

CLIENT/FAMILY TAUGHT AND ABLE TO MANAGE CLIENT'S CARE?

□Yes □No

HOME THERAPY PROGRAM

□Yes □NoSpecify details:

LANGUAGE SPOKEN IN HOME

Specify: _______________________________________



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PHYSIOTHERAPY REPORT (PAGE 2 of 2) AMBULATION Please select one of the following:

□Independent □With supervision □With 1 person assist □With 2 person assist □Non-ambulatorySpecify details:

AMBULATION - Weight Bearing Please select one of the following:

□Full □Partial □As tolerated □Non-weight bearingSpecify details:

AMBULATION - Can Progress?

□Yes □NoSpecify details:

AMBULATION - Patient uses: Please select all that apply:

□Wheelchair □Walker □Cane □Crutches □Other, specify: __________________________________

AMBULATION - can client walk up and down stairs? Please select one of the following:

□Not Applicable □Independent □Needs assistance □With supervision □No

WHEELCHAIR MANAGEMENT Please select one of the following:

□Not applicable □Independently □Needs assistance

TRANSFERS Please select one of the following:

□Independently □With supervision □With 1 person assist □With 2 person assist □Using liftSpecify details:

ADDITIONAL INFORMATION (including goals)


Last Name _______________________________

First Name _______________________________

Role _______________________________




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SPEECH LANGUAGE PATHOLOGY REPORT (PAGE 1 of 2) COMMUNICATION AND/OR SWALLOWING DISORDER(S)

Speech Diagnosis:

Swallowing Diagnosis:

HEARING (Include comments)

PRE-MORBID LANGUAGES SPOKEN (Include proficiency if possible)

ASSESSMENT(S) (Include findings and recommendations)Name of test (include date):

Summary of results (comprehension and expression):

THERAPY

a) Specify date started, where, and by whom

b) Treatment goals while in hospital

c) Treatment program



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SPEECH LANGUAGE PATHOLOGY REPORT (PAGE 2 of 2) d) Weekly frequency of therapy and length of sessions

e) Progress (how has this patient changed?)

f) Suggested goals of community Speech Language Pathologist, if different from (b)

g) Communicative status on discharge from hospital

FAMILY MEMBERS AND AGES

Please specify:

OCCUPATIONAL HISTORY

Type of employment _________________________________________

Last date of employment (MM/DD/YYYY)__ __ / __ __ / __ __ __ __

DOES THE PATIENT HAVE A HOME THERAPY PROGRAM?

□Yes □No

ADDITIONAL SPEECH PATHOLOGY COMMENTS

Specify details:


Last Name _______________________________

First Name _______________________________

Role _______________________________




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SOCIAL WORK REPORT SOCIAL WORK ASSESSMENT Brief account of psychosocial issues/concerns and Social Work involvement in hospital

OTHER SOCIAL AGENCIES TO WHOM PATIENT IS KNOWN List all that apply

NAME, ADDRESS, AND TELEPHONE NUMBERS OF PEOPLE WHO WILL SUPPORT PATIENT IN MAKING PLANS List all that apply

RECOMMENDATIONS FOR FURTHER SOCIAL WORK SERVICE/INTERVENTIONS List all that apply


Last Name _______________________________

First Name _______________________________

Role _______________________________



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