SVH054

 Jun 18	

St Vincents Private Hospital
Inpatient Rehabilitation Unit
Level 2, Avondale Avenue entrance 
Tel: (02) 6627 9263
Fax: (02) 6622 3163	(Affix patient identification label here)
URN: 
Family Name: <PtSurname>
Given Names:  <PtFirstName>
Date of Birth: <PtDoB>	Gender: <PtSex>	R
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	REFERRAL FORM REHABILITATION UNIT			
	Consent for faxing of patient info obtained <Consent for faxing of patient info obtained>
Date of referral:    <TodaysDate>	
Referral source: <Referral Source>
Phone number: <DrPhone>	Est. Date for transfer to rehab: <Est date for transfer to rehab>
Signature: 	Next of Kin: <NOKName>	Relationship: <NOKRelation>	Phone no. of NOK: <NOKContact>	GP: <UsrName>		
	RISK ALERTS:
Infection status: <Infection Status>
Site of infection: <Site of infection>
Allergies (drugs/food): <Reactions>
Cognitive impairment: <Cognitive Impairment>	  3MS SCORE <3MS Score>
Behaviour Concerns: <Behaviour Concerns>			
	MEDICAL DETAILS:
Diagnosis/Injury – date of onset: <Diagnosis/Injury – date of onset:>	Investigations:<Investigations>	  <Medical follow-up required> Medical follow-up required	Specialist: <Specialist>	Pre-existing conditions: 
<PMHNoDetail>			
	Mobility level: <Mobility level>
Walking aid: <Walking aid>
Transfers:  <Transfers>
Weight bearing status: <Weight bearing status>	Timeframe: <Timeframe>Review date <Review date>	
Continence urine: <Continence urine> Date inserted  <Date inserted>
Continence Faeces: <Continence Faeces>
Diet: <Diet>			

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St Vincents Private Hospital
Inpatient Rehabilitation Unit
Level 2, Avondale Avenue entrance 
Tel: (02) 6627 9263
Fax: (02) 6622 3163	(Affix patient identification label here)
URN:
Family Name: <PtSurname>
Given Names: <PtFirstName>
Date of Birth:	<PtDoB>	Gender:  <PtSex>	BINDING MARGIN  DO NOT WRITE	
	ALLIED HEALTH:
Occupational Therapist:  <ALLIED HEALTH: Occupational Therapist>    	
Physiotherapist: <Physiotherapist>	                        	
Speech Pathology: <Speech Pathology>	       	
Social Worker: <Social Worker>	          	
Dietician: <Dietician> 	                                                	
Rehab Goals:
Goal 1: <Rehab Goal 1>
Goal 2: <Rehab Goal 2>
Goal 3: <Rehab Goal 3>			
	Preadmission support: <Preadmission support>
Usual place of residence: <Usual place of residence>
Lives alone: <Lives Alone> 	Discharge destination: 	<Discharge destination>			
	Additional information 
(social/family support, previous functional ability, community care provider, etc):
<Additional information: social, functional, community care etc.>			
	For a person to be suitable candidate for admission they must meet all of the following criteria:
<For a person to be suitable candidate for admission they must meet all of the following criteria:>
 <Medically Stable> Medically Stable
 <Has the cognitive capacity to learn> Cognitive capacity to learn
 <Demonstrates a capacity for improvement> Capacity for improvement
 <Currently responding to therapy> Currently responding to therapy
 Requires multidisciplinary input from a minimum of two disciplines: 
<Requires multidisciplinary input from a minimum of two disciplines: Select two disciplines>
 <Motivated, understands the rehabilitation concept and is willing to participate> Motivated, understands rehabilitation concept and is willing to participate
 <Aware of referral and willing to come to the Rehabilitation Unit> Aware of referral and willing to come to the Rehabilitation Unit
			
	Name (print) : <UsrName>	Date: <TodaysDate>
Signature: 			

Patient Health Summary
Name: <PtFormalName>	<Practice>	
Address: <PtAddress>	<UsrAddress>	
D.O.B.:	<PtDoB>	<UsrPhone>	
Medicare No.:   <PtMCNo> <PtMCLine>
Medicare Card Expiry: <PtMCExpiry>		
Home Phone: <PtPhoneH>
Work Phone: <PtPhoneWk>  
Mobile Phone: <PtPhoneMob>		

Printed on <FormattedDate>

Family History

<FamilyHx>
Social History
<SocialHx>
Past Medical History
<SelectedPMH>
Allergies
<Reactions>
Immunisations
<Imm>