(Version 4.2: September 2014)
Please complete all sections in order to avoid delays processing referral.
Patient ’s name: ………………………………………………………………………………………………
Date of birth: ……………… Age: …….. Gender: ……………… NHS no.: ……………...……
Occupation: ………………………………………………………………. Marital status: ……..………
Eligibility for NHS funding confirmed?
yes/no
(eligibility must be confirmed before referral can be processed)
Name of the CCG r esponsible for the patient’s care: ……………………………………………………
Home address: ………………………………………………………………………………………………
Post code: ………………… Tel: ……………………… Email: …………………………………………
Name: ……………………………………………………… Relationship to patient: ……………………
Ad dress: ………………………………………………………………………………………………
Post code: ………………… Tel: ……………………… Email: …………………………………………
(optional, eg: relative or professional involved in patient’s care)
Name: ……………………………………………………… Role: ………………………………………
Ad dress: ………………………………………………………………………………………………
Post code: ………………… Tel: ……………………… Email: …………………………………………
Name: ………………………………………………………………………………………………
Ad dress: ………………………………………………………………………………………………
Post code: ………………… Tel: ……………………… Fax: ……………………………
Email: …………………………………………………………………………………………………………
London Specialist inpatient rehab referral and assessment form – v4.2 – September 2014
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I npatient on ……………………………… ward at ……………………………………….. hospital
At home at the above address
Ot her (please specify) ………………………………………………………………………………..
Ad dress: ………………………………………………………………………………………………
Post code: ………………… Tel: ……………………… Fax: ……………………………
Email: …………………………………………………………………………………………………………
Name: ………………………………………………………………………………………………
Ad dress: ………………………………………………………………………………………………
Post code: ………………… Tel: ……………………… Fax: ……………………………
Email: …………………………………………………………………………………………………………
Name: ………………………………………………………………………………………………
Ad dress: ………………………………………………………………………………………………
Post code: ………………… Tel: ……………………… Fax: ……………………………
Email: …………………………………………………………………………………………………………
If following a period of rehabilitation at the specialist neurological rehabilitation units, this patient is unable for any medical or social reasons to return home/into a suitable placement –
I agree to readmit patient to this hospital/to a bed at ………………………… (delete as appropriate)
Signature …………………………………………….
Name (please print) …………………………………
Title ………………………………………….
Date …………………………………………
Tel: ………………………………… Email: …………………………………………
Assessment of low awareness state
Primarily Complex Physical
Primarily Cognitive Behavioural
Advice for appropriate placement
Other, please specify…
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Each specialised rehabilitation unit in London has its own particular specialisms such as managing patients requiring complex medical care, tracheostomies, challenging behavioural issues etc. Please check individual service specifications for more details to ensure that patients are referred to the most appropriate service(s) and choose a maximum of 3 services that are clinically suitable.
Hyper-acute Rehabilitation (multiple medical co-morbidities, medical instability, etc.):

Regional Rehabilitation Unit, Northwick Park Hospital
Assessment for Prolonged Disorders of Consciousness (SMART, WHIM, CRS-R):

Royal Hospital for Neurodisability, Putney

Regional Rehabilitation Unit, Northwick Park Hospital
Complex physical, tracheostomies etc.:

Royal Hospital for Neurodisability, Putney

Regional Rehabilitation Unit, Northwick Park Hospital
Primarily cognitive/communicative and challenging behaviour:


The Thames Brain Injury Rehabilitation Unit, Blackheath
Lishman Brain Injury Unit, Maudsley Hospital
Mixed complex specialised rehabilitation:

The Heathside Neurodisability Unit, Blackheath
 Frank Cooksey Rehabilitation Unit, King’s College Hospital

Neuro-rehabilitation Unit, National Hospital for Neurology & Neurosurgery

Regional Neurological Rehabilitation Unit, Homerton Hospital

Wolfson Neuro-rehabilitation Centre
Has the suitability of the various services been discussed with the patient/family?
yes/no
Select maximum of 3 services indicating 1 st , 2 nd , 3 rd choice if applicable
Clinical Expertise
Yes (order) No
Patient/family choice
Yes (order) No
1. Blackheath Brain Injury Rehabilitation Centre
1.1. The Thames Brain Injury Rehabilitation Unit
1.2. The Heathside Neurodisability Unit
2. Frank Cooksey Rehabilitation Unit
King’s College Hospital
3. Lishman Brain Injury Unit
………
………
………
Homerton Hospital
6. Regional Rehabilitation Unit
Northwick Park Hospital
7. Royal Hospital for Neurodisability
………
Maudsley Hospital
4. Neuro-rehabilitation Unit
National Hospital for Neurology & Neurosurgery
5. Regional Neurological Rehabilitation Unit
………
………
………
………
Putney
8. Wolfson Neuro-rehabilitation Centre
………
Other non-London Complex Specialised Units
9. ………………………………………………………….. ………
10. ………………………………………………………..
Additional comments:
………
………
………
………
………
………
………
………
………
………
………
………
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Primary diagnosis: …………………………………………………Date of onset: …………………......
Date of surgery (if applicab le): ……………………………………………………………………………
Surgical procedure: ……………………………………………………………………………………...
Secondary diagnoses: …………………………………………………………………………………..
…………………………………………………………………………………..
Drug/alcohol use: ……………………………………………………………………………………………..
History of deliberate self harm: ……………………………………………………………………………...
Previous physical & cognitive function …………………………………………………………………..
…………………………………………………………………..
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CT scan:
Yes No If yes, Date
……………….
……………….
……………….
Comments/Further details
MRI:
Other:
If the patient has had a stroke, please complete the following:
Echocardiogram:
Carotid doppler/duplex:
ESR:
Auto-antibody screen:
Other:
Yes No If yes, Date
……………….
Comments/Further details
……………….
……………….
……………….
……………….
1. …………………………………………………… 4. …………………………………………………….
2. …………………………………………………... 5. …………………………………………………….
3. …………………………………………………… 6. …………………………………………………….
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Altered state of awareness:
Cognitive/communicative problems:
Behavioural problems:
Yes No Comments/Further details
Physical deficits:
Higher respiratory needs:
Physiotherapy:
Occupational Therapy:
Speech & Language Therapy:
Yes No Comments:
Psychology:
Dietetics:
Social Worker:
Please attach reports from the therapists currently involved in the care of the patient, or arrange for them to be sent.
Transfers (Tick 1)
Independent
Mobility
Walking
Assistance from 1
Assistance from 2
Hoist
Bedbound
Risk of falls Yes No
Wheelchair
Independent N/A
Supervision/help from 1 Pushed in a wheelchair
Supervision/help from 2 Independent
Has own chair
If yes, is it suitable
Yes/No
Yes/No
Level of communication: Consistent yes/no responses
Sentences
Yes No
Single word level
Full phrases
Comments/Further details
Cognitive problems:
Perceptual problems:
Ability to learn:
Other:
Dysphasia:
Expressive dysphasia:
Receptive dysphasia:
Dysarthria:
Other:
Capacity to consent: ………………………………………………………………..
If no, Has Deprivation of Liberty Safeguards been undertaken including involvement of Independent
Mental Capacity Advocate?
.........................................................................................................................
Yes No
Visual problems:
Hearing problems:
Comments/Further details
London Specialist inpatient rehab referral and assessment form – v4.2 – September 2014
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Agitation:
Yes No Comments/Further details
Wandering/absconding:
Self harm:
Verbal aggression:
Physical aggression:
One to one supervision:
Is the patient under a mental health act detention order?
Comments/Further details
Yes No
Dysphagia:
Oral feeding:
Nasogastric feeding:
Yes No
PEG feeding:
Pressure sores:
Special mattress:
Other special nursing requirements:
Urinary incontinence:
Urinary catheter:
Faecal incontinence:
MRSA:
C difficile
Tracheostomy:
Comments:
If yes, occasional
If yes, occasional
If yes, colonisation
If yes, cuffed weaning programme regular regular infection uncuffed stabilised
Lives alone
Lives with:
Parents
Husband/wife/partner
Other
Owner/occupied:
Council/housing association:
No fixed abode:
Other:
Comments/Further details
Please specify : ………………………………………………………….
Comments/Further details
Please specify: ………………………………………………..
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To be filled in by the assessor(s)
This assessment was undertaken by ……………………………………………………………………… from the …………………………………………………………………….. specialist rehabilitation unit
Unidisciplinary assessment
Assessment undertaken at the
Referring hospital/unit
Summary and recommendations
Multidisciplinary assessment
Specialist rehabilitation unit
Suitable for the following units
Home
Date of asses sment: …………………………….
Other
If other, please indicat e …………………………...
1 …………………………………..
2 …………………………………..
3 …………………………………..
No The patient is suitable for specialist inpatient rehabilitation Yes
If yes, this patient is for:
Assessment of low awareness state
Primarily complex physical rehabilitation programme
Cognitive/communicative and/or behavioural rehabilitation programme
If no, please give the reasons and alternative recommendations:
Clinical Assessments (please attach fully itemized score sheets)
Patient Categorisation Tool: …………/50
Rehabilitation Complexity Scale (v13): …………/22
Northwick Park Nursing Dependency Scale: …………/100
Patient fit for transfer for rehabilitation
Patient requires reassessment
If yes, reasons for re-assessment
Yes
Yes
No
No
Signature …………………………………………….………… Date ……………………………….
Name of the assessor (please print) ………………………… Title …………………………………
Contact telephone no. (mobile) …………………………………………………………………………...
Email: …………………………………………………………………………...
Copy of referral/assessment sent to CCG?
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