Download Healogics EHS Wound Care Referral Form, Word

1
EHS & H&R CCG WOUND CARE REFERRAL FORM
Practice:
Referred by:
GP:
Referrer Contact Number:
Patient Name:
Referrer Email:
Patient Address:
Consent for referral including transfer of personal data
and medical photography? Yes
No
Does the person have capacity to give consent? If not, has
this referral been completed in the person’s best interest?
Yes
No
Patient DOB:
Referral Date:
Patient NHS No:
Patient Ethnic Origin:
Patient Phone No:
Urgency of Referral: Low
Medium
High
WOUND DETAILS
Date of Onset:
Type of wound:
Location of wound:
BMI:
PRESSURE ULCERS:
DIABETIC FOOT ULCER
Grade: (Texas)
________________________________
Charcot joint: Yes
No
Pressure ulcer grade: 1
2
DTI:
Unstageable:
Waterlow score: At risk
High risk
3
4
Very high risk
Pressure reducing/relieving equipment :
Domestic Mattress
Static Pressure relieving Mattress
Dynamic Air Mattress
Modular cushion
cushion
Other
Domestic mattress
Static air
Alternating cushion
Heels offloaded (static air)
Other
Please specify:
Chair bound
No
No
No
No
No
Blood sugars stable:
Yes
No
Recent HBA1C:___________________
Heels placed on the floor
: (state)
Mobility: Bed bound
Referred to DFU clinic: Yes
Previous amputation: Yes
Referred to Vascular TVN:
Yes
Bone /tendon exposed: Yes
Multiple ulcer sites:
Yes
Fully mobile
Mobile with Aid
Nutrition: MUST score:
Diet : Adequate
Photograph attached /sent: Yes
No
(referrals will not be processed without images)
Healing Status: Wound healing
Deteriorating
Exudate: None
Minimal
Current Wound Treatment :
Moderate
Inadequate
Supplements : Yes
Doppler results : N/A ( Date:
Left ABPI=
RightTABPI=
Static > 6wks
Static >12 wks
e
x
High
Colour:
a
s
)
No
2
Wound Infection: Yes
Wound swab taken: Yes
Other symptoms: Cellulitis
Other: (state)
No
No
If yes state infection present (if known):
Antibiotics commenced /requested: Yes
No
increased exudate
Pain
Malodour
Pyrexia
Wound bed Condition: (show %)
Wound Dimensions (cms)
Healthy granulation(red) ________Necrosis (black)________
Max length:
Hypergranulation(raised)_____ Slough(yellow /grey)____
Undermining/tunelling: Yes
Max width:
Max depth:
No
Other:(state)
Pain: Yes
No
Peri wound/skin : (Tick all that apply):
Score 0-10
Score:
Haematoma
oedema
Analgesia: (type)
Moist/maceration
Healthy
excoriation
Dry/flaky
dermatitis/eczema
Other (state)
Medical History (tick all that apply)
Diabetes
Peripheral arterial disease
State other medical History :
Rheumatoid arthritis
Malignancy/end of life
Medications (tick all that apply)
Steroids
Warfarin
Insulin
NSAID,s
Diuretics
Tramadol
Anti hypertensives
Please list all others (including recent antibiotic therapy)
Accessibility information
Does the patient have any communication difficulties: Yes
Symbols
Email
Braille
Sign Language
(Email address)
Text
if yes please state requirements:
Telephone
Link worker
Other (please state):
For Office Use Only
Date triaged:
Signature:
Outcome
Date received:
Triaged by:
Domicillary Visit:
Large print
No
Clinic appointment:
Remote Care plan:
Date sent:_________
Appointment Date:_________ Assessment Time: ________ Assessing Clinician : ______________
Appointment confirmed with:_________________________________________________________
Special arrangements:
Translator Y / N
Communication method: Text
Email
Sign Language Y / N
Large Print
Telephone
Symbols
Comments:
Signature:
Name:
Date:
Time:
For EHS CCG send referral & photograph via nhs mail to: [email protected]
Or for enquiries call Healogics Wound Healing Centre: 01323 735588
For H&R CCG send referral & photograph via nhs mail to: [email protected]
Or for enquiries call 01424 735661
For Vascular Nurse referrals: [email protected]