Plym Neuro-Rehabilitation Unit Referral Form

Date of referral: Click here to enter a date. Hospital: Click here Ward: Click here Tel: Click here Referring Consultant: Click here Referred by (Name/Designation): Click here Tel/Bleep: Click here	Patient Name: Click here to enter Date of Birth: Click here to enter Hospital No.: Click here to enter NHS Number: Click here to enter Address: Click here to enter

CLINICAL DETAILS

Primary diagnosis: Click here
Date of onset : Click here to enter a date.
Investigations/Interventions: Click here
Other diagnoses / Past Medical History: Click here
Planned further investigations/interventions: Click here
Anticipated problems/common complications (e.g. seizures, hydrocephalus, re-bleed, etc): Click here
Psychiatric History	YES☐	NO☐
(Details, if known): Click here
Initial Glasgow Coma Score (GCS): E1-4, V 1-5, M 1-6 = 3-15 /15
Current Glasgow Coma Score (GCS): E1-4, V 1-5, M 1-6 = 3-15 /15
Time to recover to current score: Click here
Duration of post-traumatic amnesia (PTA): Click here
Rehab prescription available:	YES☐	NO☐

CPE risk assessment complete:	YES☐	NO☐	Risk:	HIGH☐	LOW☐

SOCIAL HISTORY / BACKGROUND

Click here
Smoking	YES☐	NO☐
Alcohol	YES☐	NO☐
Drug Abuse	YES☐	NO☐
Next of kin: Click here
Life history questionnaire (please attach):	YES☐	NO☐

Rehabilitation Complexity Score (RCS v 13):

Medical	None active Basic Specialist Potentially unstable Acute medical / surgical	0 1 2 3 4	M 0-4
Care/Risk	Care Risk Independent None 1 carer Low 2 carers Medium 3 carers High 1:1 supervision Very high	0 1 2 3 4	C 0-4 R 0-4 Count the higher of the two and discard the lower
Nursing	None Qualified Nurse Rehab nurse Specialist nursing High dependency	0 1 2 3 4	N 0-4
Therapy disciplines	None 1 2 – 3 4 – 5 6	0 1 2 3 4	TD 0-4
Therapy Intensity (Total therapist time)	None low level (< daily) <15 hrs/week Moderate (eg daily) 15-24 hrs/wk High (+ assistant) 25-30 hrs/week Very high >30 hours/week	0 1 2 3 4	TI 0-4
Equipment	None Basic Specialist	0 1 2	E 0-2
Total = add up	RCS 0-22/22

Bowel & Bladder Management
Bladder Continence	YES ☐	NO ☐
Catheter	YES ☐	NO ☐
Bowel Continence	YES ☐	NO ☐

Respiratory Function

Tracheostomy	YES ☐	NO ☐ (Size and type): Click here
Plan (i.e phonation valve or cuff deflation trials etc): Click here

Speech And Language Function & Swallow function

Speech& Language	Normal	YES ☐	NO ☐
Swallow	Normal	YES ☐	NO ☐
NG / PEG: Click here	Date of insertion: Click here to enter a date.

Vision / Hearing

Wears Glasses	YES ☐	NO ☐
Hearing aid	YES ☐	NO ☐

Cognition/ Perception

Orientated to TIME ☐ PERSON ☐ PLACE ☐ SITUATION ☐
Memory Normal	YES ☐	NO ☐
Insight into Current Difficulties	YES ☐	NO ☐

Mood And Behaviour

Depression	YES ☐	NO ☐
Aggression	YES ☐	NO ☐
One-to-one supervision	YES ☐	NO ☐
Any Details (i.e) Medication: Click here

Tonal Management

Splints:	YES ☐	NO ☐ (Details): Click here
Drugs: Click here

Functional Activity/ Transfers: Click here

Personal Activities Of Daily Living: Click here

Additional Information (Discharge Summary/ Progress report)

YES ☐	NO ☐ (Details): Click here

Multidisciplinary Team	Name	Telephone

Physiotherapy	Click here	Click here
Occupational Therapy	Click here	Click here
Speech and Language	Click here	Click here
Dietician	Click here	Click here
Social Services (SAP/BICA form) referral date: Click here to enter a date.

Press Ctrl + click this link to open an email to PCHCIC.PlymE@nhs.net