1. No category

CCAC IN HOME/COMMUNITY REFERRAL Request for Assessment & Medical Treatment Orders
CONTENTS
CLIENT DETAILS & DEMOGRAPHICS ........................................................................................................................................ 2
REQUEST FOR ASSESSMENT.................................................................................................................................................... 3
MEDICAL TREATMENT ORDERS (PAGE 1 of 2) ........................................................................................................................ 4
MEDICAL TREATMENT ORDERS (PAGE 2 of 2) ........................................................................................................................ 5
PHYSICIAN/NP SIGN-OFF......................................................................................................................................................... 6
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CCAC IN HOME/COMMUNITY REFERRAL DOWNTIME FORM
CLIENT DETAILS & DEMOGRAPHICS
DATE COMPLETED
M M D D
Y Y Y Y __ __ / __ __ / __ __ __ __
CLIENT DETAILS & DEMOGRAPHICS
Name
Last Name
First Name
______________________________________ ______________________________________
Date of Birth
M M D D
Y Y Y Y
__ __ / __ __ / __ __ __ __
Health Card
Number
__ __ __ __ __ __ __ __ __ __
Health Card Version
Code
Health Card Expiry
M M D D
Y Y Y Y
Date
__ __ / __ __ / __ __ __ __
MRN
Address
Number and Street
City/Town
Province
Postal Code
Phone Number
Current Location
(
) ____ - ______
Site & Unit/Clinic:
IS THERE AN ALTERNATE CONTACT FOR PATIENT?
Last Name
Yes
_________________________________________
Phone (
) ____ - ______
□
□ No
First Name
_____________________________________________
Relationship: _________________________________
IS THE TREATMENT ADDRESS DIFFERENT THAN THE HOME ADDRESS?
City/Town
Yes Number and Street
□
□ No
Phone (
Province
ON
Postal Code
) ____ - ______
IS AN INTERPRETER REQUIRED?
Yes Language(s) requested: _______________________________________________________________
No
□
□
REFERRAL OWNER
Name
Phone Number
Pager Number
Last Name
______________________________________
(
) ____ - ______ ext. _____
(
) ____ - ______
ALTERNATE STAFF CONTACT (IF APPLICABLE)
Last Name
________________________________________________
Role
________________________________________________
First Name
______________________________________
First Name
_______________________________________________
Contact/Unit Phone Number
(
) ____ - ______ ext. ____
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CCAC IN HOME/COMMUNITY REFERRAL DOWNTIME FORM
REQUEST FOR ASSESSMENT
PRIMARY DIAGNOSES/RELEVANT MEDICAL HISTORY AND REASON FOR REFERRAL
PRECAUTIONS/RISK (IF APPLICABLE) – To patient and/or provider
Behaviours
Falls
Infection Control
Infestation(s)
Please specify precautions/risks details:
□
□
□
□
□Other, specify
IS A MEDICAL TREATMENT ORDER REQUIRED? (such as: Enteral Feeding, Medication(s)/Hydration, Peritoneal Dialysis,
Tube/Drain Care, Urinary Catheter Care, Vascular Access Device Care, Wound Care/Dressing)
Yes - Complete the Medical Treatment Orders form and Allergies below
No
To be determined
Allergy Information (For example: medication, latex, tape allergies, or no known allergies (NKA)):
□
□
□
SERVICES REQUESTED
Please select all that apply and complete the associated discipline-specific reports
Case Management – no associated report
Dietitian
Home First – no associated report
Nursing (Select only when Physician sign-off not required, excluding wound care/dressing)
Occupational Therapy
Palliative Care: If client resides in Toronto, please complete and submit Common Palliative Care Referral Form.
Prognosis (e.g. less than 3 months)
____________________________________________________________
Palliative Performance Scale (%)
____________________________________________________________
□
□
□
□
□
□
□ Personal Support Worker – no associated report
□ Pharmacy – no associated report
□ Physiotherapy
□ Speech Language Pathology
□ Social Work
□ Other Services Requested, please specify: ____________________________________________________________
EXPECTED DISCHARGE DATE (IF APPLICABLE)
Date (MM/DD/YYYY) __ __ / __ __ / __ __ __ __
OTHER RELEVANT INFORMATION
COMPLETED BY: I have completed this form and reviewed required information
Last Name
First Name
Role
_______________________________ _______________________________ _______________________________
Contact/Unit Phone Number (
) ____ - ______ ext. _____
Date (MM/DD/YYYY) __ __ / __ __ / __ __ __ __
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CCAC IN HOME/COMMUNITY REFERRAL DOWNTIME FORM
MEDICAL TREATMENT ORDERS (PAGE 1 of 2)
WOUND CARE
Please specify wound description (type, location, depth, stage/category – if applicable), dressing order (cleansing, type of
dressing, frequency, packing if required, last dressing change)
For VAC wound, please specify type of pressure (continued/intermittent), amount of pressure, change frequency,
white/black foam
MEDICATION(S)/HYDRATION
Foe each medication, please specify drug, dose, route, frequency, duration, when was/will last dose be given in hospital
(date, MM/DD/YY and time), next dose due (date, MM/DD/YY and time).
If applicable, please specify VAD flushing/locking information:
VASCULAR ACCESS DEVICE CARE (e.g. CVAD/PIV) – WITH NO ADDITIONAL MEDICATION/HYDRATION
Please specify type of line, solution, and any additional VAD dressing information:
TUBE/DRAIN CARE
Please specify type, location, insertion date, specific care orders, maximum fluid removal, flushing and site dressing
change, parameters for drain removal:
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CCAC IN HOME/COMMUNITY REFERRAL DOWNTIME FORM
MEDICAL TREATMENT ORDERS (PAGE 2 of 2)
URINARY CATHETER CARE
Please specify type of urinary catheter, size, frequency of catheterization/changes, date of insertion (MM/DD/YY),
flushing order (solution, amount, frequency of catheterization):
PERITONEAL DIALYSIS
Please specify type, baseline assessment data, dialysis order (continuous ambulatory peritoneal dialysis (CAPD),
automated peritoneal dialysis (APD), exit site care) and all special instructions:
ENTERAL FEEDING ORDER AND FLUSHING
Please specify type of tube, pump or gravity, continuous vs. intermittent, formula type, volume, rate (mL/hr or number of
cans/set times), frequency, duration, flushing amount and flushing frequency:
OTHER MEDICAL TREATMENT BEING ORDERED
Please specify details:
COMPLETED BY: I have completed this form and reviewed required information
Last Name
First Name
Role
_______________________________ _______________________________ _______________________________
Contact/Unit Phone Number (
) ____ - ______ ext. _____ Date (MM/DD/YYYY) __ __ / __ __ / __ __ __ __
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CCAC IN HOME/COMMUNITY REFERRAL DOWNTIME FORM
PHYSICIAN/NP SIGN-OFF
□ Attending Physician – I approve of the medical treatment orders contained herein to be performed
Attending Physician Information
Name
Last Name
___________________________________
First Name
___________________________________
□ Resident/Fellow - I authorize the medical treatment orders contained herein on behalf of attending physician
Physician Delegate Information (Specify Attending Physician Information Below)
Name
Last Name
First Name
___________________________________ ___________________________________
Role/Specialty
□ Nurse Practitioner or Registered Nurse (Extended Class) -I approve of the medical treatment orders contained
herein to be performed
Nurse Practitioner or Registered Nurse Information
Name
Last Name
___________________________________
Role/Specialty
First Name
___________________________________
□ Chiropodist - I approve of the medical treatment orders contained herein to be performed
Chiropodist Information
Name
Last Name
_______________________________
First Name
_______________________________
□ Midwife - I approve of the medical treatment orders contained herein to be performed
Midwife Information
Name
Last Name
_______________________________
First Name
_______________________________
Attending Physician Information (If applicable)
Name
Last Name
_______________________________
First Name
_______________________________
Completed On:
Date (MM/DD/YYYY)
__ __ / __ __ / __ __ __ __
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