Patients Name:
NHS No:
Plymouth Community
Healthcare CIC
Referral and Health Needs Assessment v1
Family name
Title
Gender
Address and Postcode
(please enter current
address If different
from home address)
Employment status
Phone number
Given name
Preferred name
Date of Birth
Marital status
Preferred language
Mobile number
GP Practice &
contact number
Next of kin
Relationship
Tel no
Address
Risks (including self / others/vulnerable adult)
Ethnicity
Religion
Other
Relationship
Tel no
Address
(access details – key safe, hard of hearing)
Referral details (If self-referral address will be assumed to be as above. If in hospital identify person’s ward)
Referral date & time
Referrer name & designation
Referral source
Contact telephone number
Confirmed date of
Expected date of discharge
discharge
(inpatient only)
st
Date 1 visit required
Urgency:
(Community Nursing only)
(indicate how quickly the
referral must be actioned)
Reason for referral
Details:
(Is there a prescription chart available)
Is the client aware of the referral? (consider capacity) Yes/No If no why not?
Required venue inline with referral only:
Home
Clinic … (Include admissions to hospital)
Relevant Medical History and Observations
Allergies
Response if no further action required:
Printed name of clinician:
Signature:
Date:
Designation:
Referral and Initial Asessment DRAFT v3 Jan2012
Patients Name:
NHS No:
Plymouth Community
Healthcare CIC
Initial Assessment (to be completed with the person and/or advocate)
Yes
Problems Identified: Tick relevant box
No
N/A
Mental Health issues to include psychological and emotional well being
Behaviour
Cognition
Communication (including sensory impairment, hearing, speech etc)
Mobility
Nutrition
Continence
Skin and Tissue Viability
Personal Care
Breathing
Pain and / or Symptom Control
Printed name of clinician:
Date:
Signature:
Designation:
Referral and Initial Asessment DRAFT v1 Sept 2011
Page 2
Patients Name:
NHS No:
Plymouth Community
Healthcare CIC
Yes No
Problems Identified: Tick relevant box
N/A
Sleep Pattern
Work and Leisure
Do you have any help / support at home (e.g. family, carer, care agency,
other professions involved):
Manual Handling
Nutrition risk assessment
Tissue Viability risk assessment
Continence
Carers Assessment
Capacity assessment
CHC eligibility considered
Other:
Have issues been If yes date assessment completed or who
identified:
referred to:
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Specialist Assessments:
Current Medication
Medication
Dose
Frequency
Route
N.B.This is not a prescription chart and only current on the date recorded for this assessment.
Printed name of clinician:
Date:
Signature:
Designation:
Referral and Initial Asessment DRAFT v1 Sept 2011
Page 3
Patients Name:
NHS No:
Plymouth Community
Healthcare CIC
Patient/carer views:
Action plan/ next steps
Following this assessment we have agreed the following plan:
Supplementary records kept at base ?
Yes
No
N/A
I agree that this assessment may be shared as needed to support my care:
Yes
Yes, but with
Limitations
No
Unable to
consent
Details of any limitations:
Patient
signature
Date
Clinician
signature
Date
Print name of
clinician
Designation of
clinician
Specialist assessment to be attached as an appendice
Referral and Initial Asessment DRAFT v1 Sept 2011
Page 4