Unable to get up Yes No If yes Physio and / or OT referral required following discussion with GP, Any near miss or back onto sofa or bed Yes No Community Matron or CNOP. Care Unable to summon help Yes No direct for information on personal alarms this patient be acutely unwell Yes No Discuss with GP or integrated nursing team as appropriate. Fear of falling Yes No Consider OT and physio. Give staying steady and what to do if you fall leaflets 2. Medications 4 or more medications? Include over the counter drugs Yes No Consider referral for medication Antidepressants / Anti-psychotic / Sedative / review by GP, pharmacist or Blood pressure / Diuretic / (Circle) community matron Recent changes in medication Yes No as prescribed Yes No 3. Postural Hypotension Postural Hypotension if drop of 20mm Lighthead or dizziness on standing or getting Hg on systolic (top number), Yes No drop of 10mmHg on diastolic out of bed (bottom number) or if systolic Check lying to standing BP after lying for 10 mins is lower than 90mmHg. Lying Standing at 1 min Discuss with GP Standing at 3 mins Give advice on coping strategies 4. Alcohol Intake - units of alcohol consumed If more than 1 unit per day use brief intervention tool to discuss likely harm Per day Per week to patient 5. Nutrition and Osteoporosis Height Weight BMI Use MUST flowchart Discuss calcium and vitamin D intake Unplanned weight loss in last 3 6 months? – Yes No Check dentition and refer to dentist if MUST Score = needed Indigestion Yes No Discuss with GP Patient Name: NHS No: Calcium & Vitamin D Yes No Check taking correctly Bone sparing agent e.g. bisphosphonate Yes No If no bone protection- did parent fracture hip Yes No Check FRAX and discuss with GP -premature menopause Yes No 6. Vision Date of last eye test Eye test more than 1 year ago or deterioration in vision - prompt eye Has vision deteriorated since last eye test Yes No test (information on home eye if needed) Use Eyes Right Screener Wearing incorrect glasses Yes No if patient reluctant to attend eye test Not wearing prescribed distance glasses or Find correct glasses Yes No wears bifocals or varifocals
Unable to get up Yes No If yes Physio and / or OT referral required following discussion with GP, Community Matron or CNOP. Care direct for information on personal alarms Any near miss or back onto sofa or bed Yes No Unable to summon help Yes No this patient be acutely unwell Yes No Discuss with GP or integrated nursing team as appropriate. Fear of falling Yes No Consider OT and physio. Give staying steady and what to do if you fall leaflets 2. Medications 4 or more medications? Include over the counter drugs Antidepressants / Anti-psychotic / Sedative / Blood pressure / Diuretic / (Circle) Yes No Consider referral for medication review by GP, pharmacist or community matron Recent changes in medication Yes No as prescribed Yes No 3. Postural Hypotension Lighthead or dizziness on standing or getting out of bed Yes No Postural Hypotension if drop of 20mm Hg on systolic (top number), drop of 10mmHg on diastolic (bottom number) or if systolic is lower than 90mmHg. Discuss with GP Give advice on coping strategies Check lying to standing BP after lying for 10 mins Lying Standing at 1 min Standing at 3 mins 4. Alcohol Intake - units of alcohol consumed If more than 1 unit per day use brief intervention tool to discuss likely harm to patient Per day Per week 5. Nutrition and Osteoporosis Use MUST flowchart Discuss calcium and vitamin D intake Check dentition and refer to dentist if needed Discuss with GP Height Weight BMI Unplanned weight loss in last 3 – 6 months? MUST Score = Yes No Indigestion Yes No Patient Name: NHS No: Calcium & Vitamin D Yes No Check taking correctly Check FRAX and discuss with GP Bone sparing agent e.g. bisphosphonate Yes No If no bone protection- did parent fracture hip Yes No -premature menopause Yes No 6. Vision Date of last eye test Eye test more than 1 year ago or deterioration in vision - prompt eye test (information on home eye if needed) Use Eyes Right Screener if patient reluctant to attend eye test Find correct glasses Has vision deteriorated since last eye test Yes No Wearing incorrect glasses Yes No Not wearing prescribed distance glasses or wears bifocals or varifocals Yes No
service-directory-2016-referral-forms-v7.docx