Convalescent Care Referral Form
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1
2(Patient Name/Label)
CONVALESCENT CARE REFERRAL FORM
ADMISSION DEMOGRAPHICS - PATIENT’S PERSONAL INFORMATION
□
□
First Name
Last Name
Male
Female
Postal
HCN:
Address:
Code:
REFERRAL SOURCE
Facility / Community agency:
Sending Unit:
□
□
Yes
Consent Obtained
Primary Contact Person (CCAC Care Coordinator):
No
Phone:
Pager:
Fax:
Secondary Contact/Bed Offer Person (Referral Source/Transfer of Accountability):
Phone:
Pager:
Fax:
DIAGNOSIS
Current Medical Diagnosis:
Date of Injury/Event:
Relevant Co-Morbidities:
Surgical Date: (if applicable)
PLANNED DISCHARGE DESTINATION
□ Home
□ Retirement Home
□ Reviewed plan of care
□ Other:
Comments: Identify any barriers/challenges to discharge post convalescent care:
___________________________________________________________________________________________________________
_
CONVALESCENT CARE
Potential Sitting Tolerance (minimum 2-3 times/day) □ Yes □ No
Potential Therapy Tolerance (up to 15 minutes/day) □ Yes □ No
If No, explain:_________________________________________________
If No,explain:_________________________________________________
____________________________________________________________
___________________________________________________________
Weight Bearing Status
Movement Restrictions/Precautions:
(Consider prognosis, symptoms and treatment)
End of Life Palliative patients or patients destined for LTC are not appropriate candidates
FUNCTIONAL STATUS & GOALS (Please complete the table below):
I= Independent
S= Supervision
minA= Assist
modA= Moderate Assist
maxA= Max Assist
D= Dependent NA=Not Available
Premorbid
Current
Required Status to achieve discharge plan (SMART
Demonstrated Recent
Activity
Status:
Status
GOALS)
Progress
Bathing
Dressing
Feeding
Swallowing
Communication
Transfers
Walking
Stairs
Wheelchair Mobility
Bladder Continence
Bowel Continence
Toileting
WW518 Oct 31/14
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Parent category: Medical