Community Sub-Acute Admission Referral Form

Return the completed community sub-acute admission referral form via FAX: (03) 9231 8560 attention Sub-Acute Admission Co-ordinator For phone enquiries contact the Sub Acute Admission Coordinator on (03) 9231 8431 during business hours or the Hospital After Hour Coordinator after hours on (03) 9231 8441

¨ GERIATRIC EVALUATION AND MANAGEMENT UNIT (GEM) ¨ RESTORATIVE CARE UNIT ¨ DAY RESPITE SERVICE ¨ REHABILITATION Check the referral service requested	TEL: 9231 8435 TEL: 9231 8470 TEL: 9231 8470 TEL: 9231 3904
Admission Preference: ¨ KEW Campus - St George’s Health Service ¨ Fitzroy Campus – St Vincent’s Hospital Melbourne Check the site requested (Restorative Care and Day Respite at Kew only)	Previous Patient: ¨ KEW ¨ FITZROY ¨ OTHER
Patient Details: Name: <<Patient Demographics:First Name>> <<Patient Demographics:Surname>> Title: <<Patient Demographics:Title>> DOB: <<Patient Demographics:DOB>> Interpreter Required: Interpreter required Address: Patient Demographics.Full Address GP Name: Treating Doctor.Name GP Address: Practice.Address	Tel: Patient Demographics.Phone (Home) Mobile: Patient Demographics.Phone (Mobile) Tel: Practice.Phone Fax: Practice.Fax
Community Referrer Details: GP or Organisation: Community Referrer Name: Community Ref Name Address: Comm Ref Address Relationship to patient: Comm Ref - Tel to Pt	Tel: Comm Ref - Telephone Fax: Comm Ref - Fax
Next of Kin Details: Name: Next of Kin - Name Address: Next of Kin -Address Relationship to patient: NOK - Rel to Pt	Tel: Next of Kin - Phone Fax: Next of Kin - Fax

Reason for Referral:

Ref Reason

Relevant Past History: Include if recently admitted to a hospital.

Clinical Details.History List

Aims of Admission / Urgency of Admission:

Aim-Urgency of Adm

Please attach the following: Pathology Recent Investigations/ Imaging Any other relevant reports

Medication List and Indication:

Clinical Details.Medications - Current PRN (with comments)

Known Allergies and the reaction:

Clinical Details.Allergies With Comments

Current Status:	Independent	Assisted	Premorbid Status	Independent	Assisted
Personal Care	¨	¨	Personal Care	¨	¨
Domestic Tasks	¨	¨	Domestic Tasks	¨	¨
Community Tasks	¨	¨	Community Tasks	¨	¨
Mobility	¨	¨	Mobility	¨	¨
Transfers	¨	¨	Transfers	¨	¨
Medication Administration	¨	¨	Medication Administration	¨	¨
Continence	¨	¨	Continence	¨	¨
Cognitive Status	¨	¨	Cognitive Status	¨	¨

Current Status:	Impaired	Intact	Premorbid Status	Impaired	Intact
Cognitive Status	¨	¨	Cognitive Status	¨	¨

Coping:	Current Additional Support:
¨ Well ¨ With Difficulty ¨ Failing	¨ None ¨ Case Management ¨ Services: PCA Home Help Meals Nursing Gardening Other

Social:	Home Environment:
¨ SRS ¨ Respite ¨ Nursing Home ¨ Other	¨ Home alone ¨ Home accompanied ¨ Home with Services ¨ Home with Case Manager and Services

Sub Acute Admission Coordinator Use Only
Date Referral Received:	Referral Method:
Date Referral Reviewed:	Reviewed by:
Date Referral Accepted:	Accepted by:
Date Referrer contacted of outcome:	Signed by Admission Coordinator: