Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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]