JOINT REFERRAL FORM: Behavioural Health Service Hamilton Health Sciences, St. Peter's Hospital Site 88 Maplewood Avenue,Hamilton, ON L8M 1W9

Transcription

1 ADMISSION DEMOGRAPHIC REFERRAL Patient s Personal Information: Last Name: First Name: Male Female Address: Apt. City: Prov. Postal Code: Home Telephone: Present Location: Date Admitted (yyyy/mm/dd): Date of Birth (yyy/mm/dd): Age: Marital Status: Single Married / Partner Separated Widowed Divorced Preferred Language: Other Languages: Religion: Diagnosis: Family Physician: Phone: Fax: Consulting Physician: Phone: Fax: Health Insurance Information: Is patient covered under Ontario Health Insurance Plan? Yes No If NO, indicate other health insurance plan: Contact Information Health Card Number: Version Code: Next-of-Kin: Relationship: Power of Attoreny: Personal Care Financial Address: City: Province: Postal Code: Telephone (home): ( ) Telephone (work): ( ) Ext. Primary Contact: Power of Attoreny: Relationship: Personal Care Financial Address: City: Province: Postal Code: Telephone (home): ( ) Telephone (work): ( ) Ext. Clinical Alerts: Allergies: No Yes Specify: Diabetic: No Yes CPR Status:: Full Code: No Code Not discussed: Current Infections: MRSA: No Yes VRE: No Yes Other: Referral Source: Referral Site: Primary Contact: Phone: Ext. #: Pager: Primary Contact Alternate Contact: Phone: Ext. #: Pager: Consent received from SDM to fax referral to both: Behavioural Health Geriatric Psychiatry St. Peter s Hospital Site, HHS St. Joseph s Healthcare Hamilton Fax: (905) Fax: (905) Date: PD 7442 ( ) Page 1 of 5

2 Name: Patient Information: Date of Birth: Date: Date: Medical History (attach info as needed): Psychiatric History (include hospitalizations): Geriatric / Geriatric Psychiatry Team Involved: Yes No Name: Date of last consult: Contact Person Phone: Present Medications (please attach medication profile - MARS) Behavioural Issues: Physical: Verbal: Sexual: Behavioural Triggers: CMAI to be attached (Cohen Mansfield Agitation Inventory) Restraint Use: Past or current restraint use - Yes No Type of restraint(s) used: Reason for restraint use: Response to restraint use: PD 7442 ( ) Page 2 of 5

3 Cognitive Assessment: JOINT REFERRAL FORM: Orientation: Person: Place: Time: Memory: Language, Spatial Orientation and Coordination: Thinking: Logical Disorganized Coherent Incoherent Other: (describe) Hallucinations: Yes No Auditory Visual Olfactory Tactile Taste Describe, including the effect on client: Delusions: Yes No Describe the common theme(s), including the effect on client: MMSE or SMMSE Score: Date: Clock Drawing Assessment Communication Assessment: Hearing Aid(s)... Yes No Eye Wear... Yes No Language spoken:... Interpreter needed... Yes No Communication Problems: Functional Assessment: Washing / Dressing:... Independent Assisted Dependent Response to direct care (describe): Transfers:... Independent Assisted Dependent Ambulation:... Independent Assisted Dependent Wheelchair:... Yes No Equipment (specify): PD 7442 ( ) Page 3 of 5

4 Nutritional Assessment: Weight (kgs): JOINT REFERRAL FORM: Diet: Recent weight gain - - Yes No Recent weight gain - - Yes No How much: Height: Feeding - - Independent Assisted Swallowing Problems: Elimination Assessment: Bladder: Continent Incontinent Catheter: Yes No Bladder: Continent Incontinent Ostomy: Yes No Falls Assessment: Falls risk identified due to (check all that apply): Ambulation Climbing out of wheelchair Behaviour Climbing out of bed Cognitive / perceptual deficits Unsteady Gait Other: Date of last fall and description: Skin Assessment: Clear and Intact (present) - - Yes No; Past history of skin breakdown - - Yes No Location and description of past or present skin breakdown: Pacemaker: Yes No Last Tested: Reason for admission to current facility: _ Goals for Admission: PD 7442 ( ) Page 4 of 5

5 ORIENTATION A social worker from Geriatric Psychiatry at St. Joseph s Health Care will be in contact with the SDM prior to admission to provide information and answer questions. A tour of HHS St. Peter s Site, Behavioural Health Unit is required prior to admission. This tour provides an orientation to the service and should be attended by the SDM, interested family and the patient (if appropriate). The tour will be scheduled, following approval of the application, by the Behavioural Health social work staff. THE FOLLOWING MUST BE ATTACHED: Medication profile (MARS) Consultation reports Cohen Mansfield Agitation Inventory (CMAI) Mini-Mental State Exam Clock Drawing Assessment (if available) Recent Laboratory Results and CT/MRI if available Chart Notes (Progress Notes for last week) Interdisciplinary Assessments, i.e. TR, OT, PT, SW, SLP FAX REFERRAL TO HHS SPH AND SJHH: HHS, St. Peter s Hospital Site St. Joseph s Healthcare Hamilton Fax: (905) Fax: (905) Access Coordinator Admitting & Health Information Centre for Mountain Health Services 88 Maplewood Avenue 100 West 5th, P.O. Box 585 Hamilton, ON L8M 1W9 Hamilton, ON L8N 3K7 Phone: Phone: Ext Ext FOR ST. PETER S SITE ONLY: Co-payment discussed by: Co-payment discussed with: patient SDM: Date discussed: PD 7442 ( ) Page 5 of 5