SVH054

 Jun 18	

St Vincents Private Hospital
Inpatient Rehabilitation Unit
Level 2, Avondale Avenue entrance 
Tel: (02) 6627 9263
Fax: (02) 6622 3163	
(Affix patient identification label here)
URN: 
Family Name: <<Patient Demographics:Surname>>
Given Names:  <<Patient Demographics:First Name>>
Date of Birth: <<Patient Demographics:DOB>>Gender: <<Patient Demographics:Gender>>	

REFERRAL FORM REHABILITATION UNIT	

Consent for faxing of patient info obtained <<Consent for faxing of patient info obtained>>
Date of referral:    <<Miscellaneous:Date (long)>>
Referral source: <<Referral Source>>
Phone number: <<Doctor:Phone>>
Est. Date for transfer to rehab: <<Est. Date for transfer to rehab>>
Signature: 	
Next of Kin: <<Next of Kin name>>
Relationship: <<Relationship>>
Phone no. of NOK: <<NOK Phone>>
GP: <<Doctor:Name>>	

RISK ALERTS:
Infection status: <<Infection status>>
Site of infection: <<Site of infection>>
Allergies (drugs/food): <<Clinical Details:Allergies/Adverse Reactions>>
Cognitive impairment: <<Cognitive Impairment>>  3MS SCORE <<3MS Score>>
Behaviour Concerns: <<Behaviour Concerns>>	

MEDICAL DETAILS:
Diagnosis/Injury – date of onset: <<Diagnosis/Injury – date of onset>>
Investigations: <<Investigations>>
  <<Medical follow-up required>> Medical follow-up required	Specialist: <<Specialist>>
Pre-existing conditions: 
<<Clinical Details:History List>>	

Mobility level: <<Mobility level>>
Walking aid: <<Walking aid>> 
Transfers:  <<Transfers>>
Weight bearing status:  <<Weight bearing status>> Timeframe: <<Timeframe>> Review date <<Review date>>
Continence urine: <<Continence urine>> Date inserted  <<Date inserted>>
Continence Faeces:  <<Continence Faeces>>
Diet: <<Diet>>	

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St Vincents Private Hospital
Inpatient Rehabilitation Unit
Level 2, Avondale Avenue entrance 
Tel: (02) 6627 9263
Fax: (02) 6622 3163	
(Affix patient identification label here)
URN:
Family Name: <<Patient Demographics:Surname>>
Given Names: <<Patient Demographics:First Name>>
Date of Birth:	<<Patient Demographics:DOB>>Gender:  <<Patient Demographics:Gender>>	

ALLIED HEALTH:
Occupational Therapist:  <<ALLIED HEALTH: Occupational Therapist>>   	
Physiotherapist: <<Physiotherapist>>                        	
Speech Pathology: <<Speech Pathology>>       	
Social Worker: <<Social Worker>>          	
Dietician: <<Dietician>>	                                                	
Rehab Goals:
Goal 1: <<Rehab Goal 1>>
Goal 2: <<Rehab Goal 2>>
Goal 3: <<Rehab Goal 3>>	

Preadmission support: <<Preadmission support>>
Usual place of residence: <<Usual place of residence>>
Lives alone: <<Lives alone>>	Discharge destination: <<Discharge destination>>		

Additional information 
(social/family support, previous functional ability, community care provider, etc):
<<Additional information: social, functional, community>>	

For a person to be suitable candidate for admission they must meet all of the following criteria:
<<Admission candidates must meet all criteria>>
 <<Medically Stable>>  Medically Stable
 <<Has the cognitive capacity to learn>>  Cognitive capacity to learn
 <<Demonstrates capacity for improvement>>  Capacity for improvement
 <<Currently responding to therapy>>  Currently responding to therapy
 Requires multidisciplinary input from a minimum of two disciplines: 
<<Requires input from a minimum of two disciplines:>>
 <<Motivated, understands rehab concept & is willing>>  Motivated, understands rehabilitation concept and is willing to participate
 <<Aware of referral & willing to attend Rehab Unit>>  Aware of referral and willing to come to the Rehabilitation Unit

Name (print) : <<Doctor:Name>>  Date: <<Miscellaneous:Date (short)>>
Signature: 	

BINDING MARGIN  DO NOT WRITE	

PATIENT HEALTH SUMMARY
Date printed: <<Miscellaneous:Date>>.

<<Doctor:Name>>
<<Doctor:Qualifications>>
<<Doctor:Full Address>>
Provider No: <<Doctor:Provider Number>>
Tel: <<Practice:Phone>>

Patient Details:		
		
Patient Name: 	<<Patient Demographics:Full Name>>	
Address: 	<<Patient Demographics:Full Address>>	
Phone - Home:	<<Patient Demographics:Phone (Home)>>	
Phone - Work:	<<Patient Demographics:Phone (Work)>>	
Phone - Mobile:	<<Patient Demographics:Phone (Mobile)>>	
D.O.B.:  	<<Patient Demographics:DOB>>,  Age: <<Patient Demographics:Age>>	
Ethnicity:	<<Patient Demographics:Ethnicity>>	
Medicare Number:	<<Patient Demographics:Medicare Number>>    Medicare Expiry: <<Patient Demographics:Medicare Expiry Date>>	
DVA Number:	<<Patient Demographics:DVA Number>>	
Pension No:	<<Patient Demographics:Pension Number>>	
Warnings	<<Clinical Details:Warnings>>	

Allergies/Adverse Reactions

<<Clinical Details:Allergies>>

Family History:

<<Clinical Details:Family History>>

Social history: 

<<Clinical Details:Social History>>

Alcohol: <<Clinical Details:Alcohol>>
Smoking: <<Clinical Details:Smoking>>
Smoking Quiting Status: <<Clinical Details:Smoking Quitting Stage>>

Current medications:

<<Clinical Details:Medication List>>

Current active problems:

<<Clinical Details:History List>>

Past medical history:

<<Clinical Details:History List>>