Convalescent Care Referral Form Page 2
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1
2(Patient Name/Label)
FUNCTIONAL COGNITIVE STATUS (Please complete table below using “intact’ or “impaired”
Applicant must demonstrate consistent carryover of learning within current level of cognitive functioning
Element
Premorbid
Current
Required Status to achieve discharge plan
Demonstrated
Recent
Status:
Status:
(SMART GOALS)
Prog
ress
Carry-over/New learning
Ability to follow instructions
Orientation (person, place, time)
Insight
Judgment
Identified Behaviors (exit seeking, physical
aggression, resistance to care)
☐ Physical
☐ Chemical
☐ None
☐ Bed Alarm
Restraints Required
MOCA Score (when available) :
CLINICAL ALERTS (Please provide details where available. Indicate “NA” if not applicable):
Current Isolation Status ☐ Yes ☐ No
Positive for: ☐ MRSA ☐ VRE ☐ C Diff ☐ Other ☐ Infection or Lab Report
Allergies: ☐ Medication ☐ Environmental ☐ Food
Weight:
Height:
☐ Wound Location:
☐ Diet Type :
☐ BiPAP( pt must bring own machine)
☐ See Wound Report
☐ Diet Texture :
☐ CPAP ( pt must bring own machine)
☐ Time to task
☐ Swallowing or SLP Consult
☐ Fistula
☐ Oxygen flow L/m:
☐ Dialysis
☐ Perm Catheter
☐ NP ☐ venti-mask ☐ high humidity
☐ Hemo/Schedule:
☐ None beyond stage 2
☐ RT Required
☐
Contact to Renal Clinical to determine
☐ Chest X-ray
medical stability and site option for dialysis
☐ Drains
Date:_________________
☐ Catheter □ Suprapubic
*
(must be 90 days before admission)
☐ Ostomy/Colostomy:
☐ Size:
☐ Independent ☐ Assist
☐ No Abdominal or Chest Drains
☐ Ostomy supplies – See report
*
Patient to provide own, or cover own
costs
☐ One Person
☐ Two Person
Transfers:
Equipment Items Needed:
☐ Equipment: (include all measurements)
Name:
Measurements:
☐ Specialty Bed / Mattress (eg Bariatric, air mattress, etc):
☐ Other:
_________________________________________
*
Call ahead for all Specialty Equipment
Required Documents
☐ MOH – Application for Determination of Eligibility for Long-Term Care
Home Admission/Consent
☐ 551A - CCC Rehab Convalescent Medical Stability & Program Readiness
Fax remaining documents to WWCCAC within 24
☐ 551B - Change in Status Form
hours
☐ 418 - Short Stay Facility Choice List
☐ 427 - Placement Services Designate
Out of Region referrals must include all documents
☐ 436 - Placement Supplement
with this referral form
☐ 442 - Eligibility Determination
☐ MOH - Health Assessment
☐ Chest X-ray Results
CCAC Fax: (519) 742-0635
WW518 Oct 31/14
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