SLHD - Out of Hospital Care intake form

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Referrer details

Name *

Position *

Referring facility *

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

please specify *

Ward/Service *

Contact number/pager *

Email address *

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Client information

Family name *

First Name *

Date of birth *

MRN *

Gender *

Male
Female
Not specified
Indeterminate/intersex/unspecified

Address *

Phone number *

Interpreter required? *

Yes No

Preferred language *

Is the client of Aboriginal or Torres Strait Islander origin? *

No - neither
Yes - both
Yes - Aboriginal
Yes - Torres Strait Islander

Does client have a carer/contact person? *

Yes
No

Carer name *

Relationship to client *

Carer contact *

Does carer wish to attend assessment? *

Yes
No

Current GP *

GP contact number *

GP practice suburb *

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Referral details

Reason for referral *

To facilitate hospital discharge
To prevent hospital readmissions
To remain at home as long as possible

If client is an inpatient, are they cleared from medical perspective for discharge?
(please note these clearances will be required prior to discharge from hospital for OHC clients) *

Yes
No
N/A

If client is an inpatient, are they cleared from an allied health perspective
(please note these clearances will be required prior to discharge from hospital for OHC clients and relevant reports/staff contact details attached to this referral) *

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

If current inpatient, what is estimated discharge date? *

Reason for this hospital admission *

Medical background * (please note physical and mental health conditions and cognitive status)

Does the client have a life-limiting illness, in the deteriorating or terminal phase? *

Yes No

Please specify palliative care team involved and contact details

What is client's current Australia-modified Karnofsky Performance Score? *

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

What is the clients current phase of palliative care? *

Stable
Unstable
Deteriorating
Terminal

Does the client have an Advanced Care Directive in place? *

Yes
No

If yes, please comment if this is in SLHD eMR or where else located

Social situation *(please note clients living situation, community access and people involved in care/life)

Mobility and transfers
(please choose multiple options if applicable) *

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

Please specify mobility aid/equipment used *

Falls history *

None
Greater than 2 in a year
Less than 2 in a year

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Service request details

Does the client have formal services?*

No
Yes - CHSP
Yes - HCP
Yes - NDIS
Other

Please specify service provider/service types/HCP level/progress with NDIS application and any reference numbers as relevant to the services in place *

If you are seeking a SASH package, has the client*

Made an NDIS application
Been rejected by the NDIS
Not had any contact with the NDIS
N/A – not seeking a SASH package

Does the client have any informal supports? *

Yes
No

Please specify who supports and what support they offer *

Service type/s required from this referral
(all packages include case management) *

Personal care
Transport
Domestic assistance
In-home respite
Shopping
Meal preparation

Are there any identified WHS or safety issues in the home impacting on service delivery/safe discharge? *
(e.g. squalor, hoarding, pets, others living in the home, history of aggression, equipment available,
availability of food)

Upload/Attach a file - as PDF:
Please make sure that your attached file should not include any special character
( If you are referring from an external hospital, please upload Allied Health Reports for clients wishing to access Personal Care (OT) and Transport (PT). )

Required!