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Out of Hospital Care intake form

* Required Fields. Please submit your application by clicking the 'SUBMIT' button.

 

Does the client consent to receiving services in the home if accepted onto the OHC program?  : *
Yes       No

A referral cannot be submitted unless the client
consents to receiving services in the home

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Referrer details

Balmain Hospital
Canterbury Hospital
Concord Hospital
Royal Prince Alfred Hospital
RPA Virtual Hospital
Out of SLHD public hospital (please specify)
Private Hospital (please specify)
SLHD Community Services
Community services - outside SLHD
Other (please specify
*
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Client information

Male
Female
Not specified
Indeterminate/intersex/unspecified
Yes       No
No - neither
Yes - both
Yes - Aboriginal
Yes - Torres Strait Islander
Yes
No
*
Yes
No
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Referral details

To facilitate hospital discharge
To prevent hospital readmissions
To remain at home as long as possible
Yes
No
N/A
Yes - all allied health interventions are complete
No - allied health intervention/s is/are not yet complete
N/A - client was not referred to inpatient allied health as independent

Yes       No
50: Considerable assistance and frequent medical care required
40: In bed more than 50% of the time
30: Almost completely bedfast
20: Totally bedfast and requiring extensive nursing care by professionals and/or family
10: Comatose or barely rousable
Stable
Unstable
Deteriorating
Terminal
Yes
No
Independent - nil aid
Independent with aid
Supervision - nil aid
Supervision with aid
1 assistant - nil aid
1 assistant with aid
2 assistants - nil aid
2 assistants with aid
Hoist transfer
Wheelchair user
Immobile - managed in bed
None
Greater than 2 in a year
Less than 2 in a year
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Service request details

No
Yes - CHSP
Yes - HCP
Yes - NDIS
Other
Made an NDIS application
Been rejected by the NDIS
Not had any contact with the NDIS
N/A – not seeking a SASH package
Yes
No
Personal care
Transport
Domestic assistance
In-home respite
Shopping
Meal preparation

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Page Last Updated: 20 February, 2023