Va Form 10-0454 - Military Treatment Facility Referral Form To Va Liaison Page 3

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[As appropriate:]
REFERRALS TO POLYTRAUMA WILL NEED TO INCLUDE THE FOLLOWING:
History & Physical
Notes from theater,Germany, Medivac flight note, etc.
MD progress notes. If pt has fractures include ortho note w/ weight bearing status & any other restrictions.
Include notes from Specialty Services i.e. neurosurgery, neurology, ID, plastics, ophthalmology
Current lab work: CBC, comprehensive metabolic panel, urinalysis, and others as appropriate (i.e. INR, arterial blood gases, etc)
Cumulative microbiology results
Cumulative results of cerebrospinal and any other fluid analysis (i.e. pleural, ascitic, synovial, etc.)
Current medications
Radiology reports for CT scans, MRI's, ultrasounds, vascular studies, special procedures, angiograms & list of radiology studies performed
OR notes (especially regarding all implanted devices such as pegs, trachs, stents, filters, etc.)
Recent therapy notes from OT, PT, & SLP
Neuropsychology testing performed
Social Work psychosocial assessment
Interim summary describing the hospital course and complications to date
Patient's Last Name:
Patient's SSN:
Page 3 of 3
VA FORM
10-0454 MAR 2009

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