Download Care Home Referral Form - Lancashire Care NHS Foundation Trust

IF COMMUNITY NURSES VISIT THE CLIENT PLEASE
CONTACT THEM REGARDING CONTINENCE ISSUES
CARE HOME CONTINENCE REFERRAL FORM
As a RGN/Carer you have regular close contact with the resident and will be very familiar with their continence issues, you can provide
invaluable holistic information about the individual by completing this assessment form to help plan continence care. This should be
done before requesting a Clinical Assessment by a Continence Specialist Nurse
Name
NHS No
D.O.B
Address
Postcode
Gender
Tel Number:
Date of Admission:
Residential 
Previous
Home
Address:
Nursing 
Please tick
Named GP
Faith
Practice
Name
Postcode
Veteran?
No  Yes 
Known
Allergy
No  Yes 
Details:
Learning Disability 
Additional
Needs
Communication 
Issues
Capacity to Consent to referral No  Yes 
Date Capacity tested
Who
holds the
LPA?
Lasting Power of Attorney in Place for Health? No  Yes 
Medications and Home Remedies Taken – Please
send in MARS Sheets
Medical History
Alcohol
No  Yes 
Units per week ?
Smoker
No  Yes  How many per day?
What are you hoping to achieve by referring to the service?
Current Incontinence Issues Please complete a Baseline Continence Chart for 3 days urinary, 7 days faecal to
identify the number and pattern of incontinence episodes
Urine Incontinence
None 
Day

Night

Weekly

Faecal Incontinence
None
Leakage?

Daily

Weekly

Urine Tested
Occasional 
Amount of Urine
On Standing Up

Negative/clear

Light (Damp Pants)

Before reaching the toilet

Cloudy/Foul Smell

Moderate (Wet Pants)

Constant Dribble

Infected

Heavy (Needs Changing)

Without Warning

MSU Sent - Date
Present Bowel Habit
Open Daily
Bristol Stool Type (circle)

3-4 Times a Week
1
2
3
4

5
6
7
(Please see chart)
Less than 3 times a week

NAME:
NHS No:
Fluid Intake
Height
How many drinks offered a
day
Amount of Drink consumed
1
Weight
2
ALL
3
¾
4
5
½
¼
Current MUST Score
6
0
Date Completed
Patient preferred drink
choice
Reluctance to drink?
7
Mobility Levels
1
2 or above
No


Yes
Aids Used

Fully mobile

Chair bound
Able to get off the Toilet
Alone
Handrail in Toilet
No
Needs Assistance


Bedbound
Assisted

Yes 
Raised Toilet seat
No

Yes

Environmental Factors – Time taken to reach Toilet from (minutes)
Lounge
Dining Room
Bedroom
Bedroom Commode
Dressing Ability
Independent


Some Support needed

Cannot dress/undress
Current Care Plan in place to support continence needs
Daily Fluid Chart

Daily Bowel Charts

Daily Food Charts

Urine Outputs

Sheath with Drainage

Urinal/Bedpan

Catheter Intermittent

Catheter Long Term

Reusable Pads

Disposable Pads

Kyle Sheets

No 

If so Number of pads used in 24 hours
Leakage occurs with pads?
Regularly 
Day/Night/Both
Please state type of current pads used
Occasionally
Delete as appropriate
PLEASE USE THIS SPACE FOR ANY ADDITIONAL INFORMATION THAT WILL AID ASSESSMENT
FORM COMPLETED BY MAIN CARER AND DESIGNATION / R.G.N. / CARER
SIGNATURE
PRINT NAME
DESIGNATION
DATE
HOME MANAGER
SIGNATURE
DATE
Post : Continence Service, Clayton Brook Clinic, 59/60 Tunley Holme,
Clayton Brook, Preston, PR5 8ES
Email: [email protected]
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FAX : 01772 678084