Walkergate Park Neuro rehabilitation and Neuropsychiatry Inpatient - Referral Form :: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

Inpatient Services

Neurorehabilitation and Neuropsychiatry

Any individual with acquired brain injury or other neurological condition, who has the potential to benefit from assessment and/or rehabilitation, can be referred to the service. This can be done by any health or social care professional. We do not accept self referrals.

We offer various streams of intervention including, Neurobehavioural, Neuropsychiatry, Neurorehabilitation, Specialist Prolonged Disorder of Consciousness (PDOC) assessment and cognitive assessments. In light of the above information, if you still feel your patient is appropriate for our service then please continue.

In order to process your referral without delay, please provide us with the patient’s demographics and answer the following questions on pages 1-4 and return the form in full. This will aid us in directing your referral to the most appropriate service. Walkergate Park aims to assess patients within 10 working days of receipt of referral as per service specification (NHS Standard Contract for Specialised Rehabilitation for Patients with Highly Complex Needs of all ages) and national standards.

We do not accept self referrals.

We do not accept referrals from critical care settings such as High Dependency and Intensive Care units.

Patient details

Title Required

Forename Required

Surname Required

Home telephone number

Mobile number

Home address Required

Address 1

Address 2

City

Country

County

Postal Code

Is the above your usual residential address? Required

Yes

If no, please provide usual address:

Patient NHS number

Patient RIO number (if applicable):

Date of birth Required

Ethnicity Required

Gender Required

Current location of patient Required

Home

Other

If other, please add full address and telephone number:

Date admitted (if appropriate)

GP name, full address and telephone number: Required

Next of Kin’s name, full address and telephone number: Required

Patients Occupation and employment status: Required

Social Worker’s name, telephone number and email address (if applicable):

Referrer's details

Title Required

Job title Required

Forename Required

Surname Required

Location/base Required

Consultant Required

E-mail address Required

Telephone / extension

Therapy team

Name and contact details: (PT, OT, SLT, Psychology) Required

Any additional information

Patient's condition

What is the patient’s:

Neurological diagnosis and relevant dates?
Brief Medical history?
Psychiatric history?
Current medications?

Please give details: Required

What is the main reason for referral and the patient’s current presentation? Required

Please note: Therapy input is required to complete this section.

What are the patient’s functional rehab goals for admission? Please provide details, e.g. Physical, cognitive. Required

Is the patient currently medically stable? Required

Yes

Is the patient on IVs? Required

Yes

Is the patient on oxygen? Required

Yes

All nutritional needs met by NG? Required

Yes

Please note: We do not accept referrals directly from critical care areas.

Does the patient require supervision? Required

Yes

If yes, what level of supervision?

Does the patient's level of consciousness fluctuate? Required

Yes

Is the patient currently barrier nursed and/or do they have any infections? Required

Yes

If yes please provide details below:

Comments

Is the patient’s behaviour a consequence of a brain injury and difficult to manage? Required

Yes

If yes, please describe the behaviour:

Is the patient displaying any of the following?

Agitation Required

Yes

Wandering Required

Yes

Physical aggression Required

Yes

Verbal aggression Required

Yes

Is the patient at risk of harm to self or others? Required

Yes

Please provide details of the nature and frequency of incidents:

Please indicate the closest description to patient’s status. Required

Alert and Orientated

Alert and Disorientated

Awake but not fully aware (which has lasted for longer than 4 weeks since the illness or injury)

If not conscious, please list medications with doses:

Has a referral to Walkergate Park been discussed with the patient and/ NOK and consent been given to refer?

Discussed with patient and/NOK Required

Yes

Consent provided Required

Yes

Lacks capacity Required

Yes

If yes, is there a DOLS in place?

Yes

If patient lacks capacity, please enter the date and details of decision made:

Has there been any challenges with family or visitors whilst under your care? Required

Is the patient independently mobile? Required

Yes

If no, please enter method of transfer/aids:

Does the patient have a shunt? Required

Yes

If yes, type of shunt?

Is it programmable?

Is it MRI compatible?

Does the patient have pressure damage? Required

Yes

If yes, please enter grade and location:

Is the patient PEG or NG Fed?

PEG Required

Yes

NG Required

Yes

PEJ Required

Yes

If answer is yes to any of the above, please enter what it is used for, type and date of insertion:

Does the patient have a catheter? Required

Yes

If yes, please enter size and date it was last changed:

Does the patient have a tracheostomy? Please note Walkergate Park only accepts uncuffed tracheostomies. Required

Yes

If yes, please enter size, date it was last changed and level of intervention required.

Has decannulation been attempted? Required

Yes

If yes, please provide outcome and detail any known issues:

Can the patient be left unsupervised for any length of time? Required

Yes

If yes, please enter current level of supervision:

Does the patient have a history of drug/alcohol abuse?

Current Required

Yes

Historical Required

Yes

If yes, please provide further information:

Does the patient require a translator? Required

Yes

If yes, please specify language:

Has a potential discharge destination been discussed and identified? Required

Yes

If yes please specify:

Has a referral been made to another service? Required

Neuro-rehab ward

Other ward

Community placement

If ‘other ward’ please specify speciality:

Please confirm outcome of referral:

Please provide any further information you feel is relevant below:

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Walkergate Park Neuro rehabilitation and Neuropsychiatry Inpatient - Referral Form

Inpatient Services

Neurorehabilitation and Neuropsychiatry

Patient details

Referrer's details

Patient's condition

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Walkergate Park Neuro rehabilitation and Neuropsychiatry Inpatient - Referral Form

Inpatient Services

Neurorehabilitation and Neuropsychiatry

Patient details

Referrer's details

Patient's condition

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