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Care Home Continence Patient Referral Form

Please select from the following before proceeding

Start new referral
Retrieve previous referral progress

Email Address

Reference Number

Verification Code (Please enter the code emailed to you)

This form should only be sent to us if you have the consent of the client or their advocate.
Please perform a urinalysis for screening purposes, and inform GP of results.

Assessor Details

*First name

*Last name

This must be an email address which is checked regularly and not an individual email address.

*Email Id

*Designation

VERIFIER/COUNTERSIGNATORY for Nursing Home client assessment (MUST be verified and countersigned by a Registered Nurse)

*Full Name:

*Designation:

*Does next of kin give consent for the information provided above to be shared with the client's GP and other health professionals?

*Please provide next of kin details: name and relationship to patient along with contact number and address

*Does the care home give consent on the client's behalf for the above information to be shared with the client's GP and other health professionals?

Medical History & Symptomatic Information for Client

*Patient First Name

*Patient Last Name

*Date of Birth

*NHS Number

*Address

*Care Home Telephone No

*Nursing Home Client or Residential Home Client?

*Medical/Surgical History

*Allergies

*Current Medication (Please include name, dose and time)

Consent

Consent must be sought to share personal information with Northamptonshire Healthcare NHS Foundation Trust and other organisations that can offer support relevant to this referral

*Tick this box to confirm that consent has been discussed and received

Medical

*If reassessment, please briefly explain the problem:

*Is your client under hospital care for bladder and bowel problems?

If yes, please specify with more information:

*Is blood seen in urine?

*If yes, what action has been taken?

*Is mucus seen in urine?

*If yes, what action has been taken?

*Total number of urine infections in the last 0 – 6 months

*Total number of urine infections in the last 0-12 months

*Has a urinalysis been performed?

*Has the GP been informed of the result?

*Is a urinary catheter in situ?

*When did the client become incontinent of urine?

*What other aids are used to help client pass urine?

*On average how many times does the client ask for, or go to the toilet to pass urine in a 24 hour period?

*On average, how many times does the client use the toilet in the night to pass urine?

*Is the client faecally incontinent?

*When did they become incontinent?

*How often does the client open their bowels?

*What type of stool is passed? (refer to Bristol Stool Chart)

*Is blood seen in faeces?

*If yes, what action has been taken?

*Is mucus seen in faeces?

*If yes, what action has been taken?

*Has there been any change to the client's bowel habit or stool type recently?

*What changes have there been?

*Have these changes been referred to the GP?

PADS

*What pads are currently being used?

*Brand & Type

*Absorbency

*Client hip size in cm

*Client waist size in cm

*Is the client's skin intact on the bottom/groin area?

*Is a barrier cream being used?

Which barrier cream is being used?

*How does your client mobilise?

*How many carers assist?

*Is your client able to sit on a toilet/commode?

*If no, why not?

*What help is required to use toilet e.g. prompts, help to wipe self, help to change clothing?

*Is there any other information we should be aware of regarding this client's continence problems and management? i.e. products tried, behavioural issues, physical disabilities, dexterity issues, pad removal etc.

Attachments

Please ensure you have provided 3 days of Fluid Baseline Charts

*FLUID BASELINE RECORD CHARTS TO BE ATTACHED

Please ensure you have provided 7 days of records for the Bristol Stool Chart

*BRISTOL STOOL CHART TO BE ATTACHED

Please ensure you have provided 7 days of records for the Food Chart

*FOOD CHART TO BE ATTACHED

Please upload any other information relevant for this referral. Please note we accept a maximum of 5 documents, with a maximum 5MB per document, please limit to 5MB per document.

Document Name	Upload Docs

NHFT Referral Forms

Care Home Continence Patient Referral Form

Please select from the following before proceeding

Assessor Details

Medical History & Symptomatic Information for Client

Consent

Medical

PADS

Attachments

Thank you for submitting a referral. Your response has been recorded.