Early Supported Discharge for Stroke Referral Form
Patient Name:
Hospital no:
DOB:
Address:
GP name:
Practice:
Address:
Phone number(s):
Next of Kin:
Relationship to the patient:
Phone number:
Phone number:
Other contacts:
History of admission and stroke symptoms:
Type of stroke: TACI / PACI / POCI / LACI
Cause of stroke:
Past medical history:
Why are you referring to ESD? e.g. Which disciplines will be required to provide input?
Criteria
Do the patient and family know
you are making this referral to
ESD?
Confirmed diagnosis of new
stroke
Is the patient medically fit to go
home?
Is the patient continent?
Yes
No
Comments
CT result and date:
Predicted discharge date:
Please send a medical discharge summary at point of discharge. Buff
notes must be returned to the JR Stroke Unit – ESD Office immediately
on discharge.
If no, how is it managed?
Is the patient managing eating
and/or drinking?
Specify any modified diet or interventions:
MUST Score:
Date:
If >2 please send a copy of the latest MUST score with this referral.
Does the patient have any
difficulties with communication?
Please state specific problems here:
Is the patient able to manage
their own medications?
Are there any other nursing
needs? e.g. pressure sores
Does the patient live alone?
Do they have anyone that can
support with shopping, laundry,
cooking and cleaning etc?
Please send a Speech and Language discharge summary if follow-up is
required.
Specify if any system required?
Please specify:
If no, specify who with?
Criteria
Yes
No
Does the patient require care
visits?
Did they have any preadmission social support?
Have you noticed any
concerns regarding the
patient’s cognition,
perception or memory?
Has the patient been
screened or assessed for
mood disorders?
Has a home assessment
been completed?
Comments
Details of support required:
Date care requested:
If yes, briefly specify what help they had, who provided it and when.
If yes, please send an occupational therapy discharge summary with details
of any assessments (including MMSE)
If yes, please send a copy of any assessments e.g. Hospital Anxiety and
depression Scale (HADS)
If yes, give date of OT access/ home visit/ brief summary of outcome or
send a copy of the home visit report with this referral.
If no, does a visit need to be completed?
A member of the ESD team may be able to assist with this visit. Please
contact the team to make arrangements.
Current mobility:
Ability on stairs:
Provisional
timescale:
Goals: Please state at least one goal for each discipline required. Set by the MDT.
Outcome measures (e.g.) 9HPT, Berg, TUAG
Name of referrer and designation:
Telephone Number:
Ward:
Score:
Date:
Consultant:
Section below for use by ESD team
Clinician name/designation:
Referral received date/time:
Signature:
Date of ESD assessment visit if carried out prior to decision:
Decision: Accept / Defer / Decline
(please circle)
Date:
Comments:
Discussed with the team?
If accepted, planned date of
admission to ESD:
Please EMAIL the completed form and additional information to oxford.esd@nhs.net
or FAX to JR Stroke Unit – 01865 851040
Contact ESD team on 01865 221180 (JR Stroke Unit) or 01865 572723 (ESD Office) or Lead Therapist
mobile 07717587631
Patient name:
DOB:
Hospital number:
Early Supported Discharge for Stroke Referral
Please retain for your records
Yes, No
or N/A
ESD Referral checklist
Medical discharge summary sent to ESD team
Buff notes returned to JR Stroke Unit, ESD office
Speech and Language discharge summary sent
FIM paperwork sent
MUST Score paperwork sent
Occupational therapy home visit report sent
Occupational therapy discharge summary sent
Physiotherapy discharge summary sent
Patient name:
DOB:
Date referred:
Please FAX referral information to: Oxford Stroke Unit – 01865 851040
The ESD team can be contacted on 01865 572723 (ESD Office) or 01865 221180 (JR Stroke Unit)
or Lead Therapist mobile 07717587631