Intermediate care (magnolia unit) referral form – 3 page document

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INTERMEDIATE CARE (MAGNOLIA UNIT) REFERRAL FORM – 3 PAGE DOCUMENT

Name: Ethnic origin

Address: Post Code:

Tel: Date of Birth:

Emergency contact: Relationship:

Address: Home Tel:

Work Tel:

Patient’s GP:

Surgery: Tel: ……………………………………………….

Has the patient consented to the referral: YES/NO Has NOK/carer been notified: YES/NO

Referred by: …………………………………………….. Team/Ward …………………………………………..…

Seen by GP on (if community referred: ……………………………………………………………………………………..

Note: Referral will not be considered for review unless all areas are completed.
Inpatient Details: Admission Date ……………… Time ……………. Location/Source: ………..………………….
Reason for Admission/Referral: …………………………………………………………………………………………………….

……………………………………………………………………………………………………………………………………

Current Medical Issues/Status:
Weight: kgs ………….. Body Dynamics Issues? YES/NO Details: …………..…………………………………..

Continence: Bladder ……………………….. Bowel ………………………………..

Pressure Issues: YES/NO Details ……………………………………………………………………………………….

Leg Ulcers: YES/NO Details ……………………………………………………………………………………………….

MRSA Positive: YES/NO Details………………………………………………………………………………………..

Barrier Nursing Required: YES/NO Details …………………………………………………………………………….

Bloods/Investigations: ………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………

Current Medication: …………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………….

MSU: Positive? YES/NO Details (including date sent): …………………………………………………………….

X-Rays: YES/NO Details …………………………………………………………………………………………………..

Weight-Bearing Status: FWB YES/NO PWB YES/NO NWB YES/NO

POP fitted: YES/NO Details……………………………………………………………………………………………

Orthopaedic Review Date (if applicable): ………………………………………………………………………………….

Future Routine Appointments: YES/NO Details:………………………………………………………………………

Sensory Impairments:
Vision: YES/NO Details…………………………………………………………………………………………………..
Hearing: YES/NO Details………………………………………………………………………………………………..
Past Medical History:
Neurological Pathology: ……………………………………………………………………………………………………

Cardiac: ……………………………………………………………………………………………………………………….

Cognitive: …………………………………………………………………………………………………………………….

Respiratory: ………………………………………………………………………………………………………………….

Orthopaedic: …………………………………………………………………………………………………………………

Other: ………………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………….

Cognitive Assessment/Issues:
MMSE Score (to be completed if AMTS 7 or below): Score: ……………….. (please attach a copy of MMSE)

Behavioural Issues: YES/NO Details…………………………………………………………………………………..

Social Assessment/Issues:
Environmental (home) Hazards/Issues: YES/NO Details…………………………………………………………..

Safeguarding Issues Identified: YES/NO Details………………………………………………………………..

Family/NOK Support: ……………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………….

Mobility/Functional Level:
Functional Assessment Sheet: Please complete and attach with referral.

Current Mobility Aid: ……………………………………………………………………………………………………..

Hoist Equipment Required: YES/NO Details ……………………………………………………………………….
Known Allergies: ………………………………………………………………………………………………………..

I confirm that the above named patient is medically stable for admission to (please tick)
Magnolia (No Diagnostic facilities. Medical cover out of hours via Barndoc) Fax 020 8702 5691
Name of Referrer and Designation
Signature: ……………………………………. Contact no: ……………………………. Date: ……………………….

SOCIAL / HOME INFORMATION
Lives: Alone  With  ……………………………………………………………………………….…………………… Services: CP (Enablement)  CP (Brokerage)  DN  SW  Other: …………………………………. Services Details: ……………………………………………………………………………………………………………………………... Social support (e.g. family/neighbours): …………………………………………………………………………………………………… House  Bungalow  Maisonette  Flat  Floor: ……… Ground Floor Set Up YES/NO Tenure: O/O  Council  Private Landlord  HA  Warden-Controlled 
FUNCTIONAL / MOBILITY ASSESSMENT
I = Independent MI – Modified Independence A = Assistance D = Dependent
Mobility		Previous (Subjective) Level	Present (Objective) Level
Indoors
Outdoors
Stairs
Steps
Transfers
Bed Type
Chair Type
Toilet
Commode
Personal ADL
Washing/ Technique
Dressing
Toileting
Continence
Medication
Feeding/Drinking
Domestic ADL
Meal Preparation
Eating Location
Shopping
Housework
Processing (AMTS)
Orientation	Day Month Year Place
ST Memory	Ball Car Man
LT Memory	Address Tel No DOB /10
Equipment At Home:
Completed By: Therapist Name: ……………………………… Signature: ………………………….. Designation……………………. Contact no: Date:……………………………………………………….

Magnolia Unit Revised 2013 Phone: 020 8702 5690 Fax 020 8702 5691

Intermediate care (magnolia unit) referral form – 3 page document

Mobility

Transfers

Personal ADL

Domestic ADL