"Common Summary Assessment Report Form" - Ireland

This Ireland-specific "Common Summary Assessment Report Form" is a document released by the Ireland's Health Services.

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COMMON SUMMARY ASSESSMENT REPORT
Please complete all sections clearly in block capitals. Read guidance notes before completing
I confirm that the assessment process and purpose has been explained to me. I consent that information may be
shared as appropriate by relevant health and social care professionals in the processing of this application.
Signature ___________________________________________ Applicant/Specified Person Date ___________________
(Delete as appropriate)
:
1. SOURCE OF REFERRAL (PLEASE TICK)
Community Hospital
Acute Hospital
GP
Mental Health
Community
Nursing Home
Name of Referring Location: _____________________________ Date of Referral: _____________
2. PERSONAL DETAILS:
First Name: ______________________ Surname(s): ______________________ Preferred Name: ______________________
Current Address:
Home/Past Address (If relevant):
Tel No(s):
_________________________________
_________________________________
______________________________
_________________________________
_________________________________
Date of Birth (DD/MM/YYYY)
Medical Card No: ___________________
Hospital Number:___________________
______________________________
PPS No. : ________________________________________________________________________________________________________
3. PERSONAL CIRCUMSTANCES:
Marital Status:
Single
Married
Widowed
Separated
Divorced
Other
Living Circumstance:
Alone
With Spouse
With partner
With family
With carer
With Other
Describe Housing situation (See guidance document):
Who is the Principal Carer: _______________________________________________________________________________
What level of support do they provide?
(Please include contact details):
Assessment of Carerʼs needs completed?
Yes
No
(Please attach if available)
Identify any family members, neighbours, friends who provide support:
Contact Person/Specified Person/Care Rep: _______________________________________
Relationship to applicant?
(Contact details address/phone/mobile):
_______________________________________
__________________________
___________________________________________________________________________
GP: _________________________________________________
Contact Details: _________________________________
PHN &/or CMHN: ______________________________________
Contact Details Health Centre: _____________________
4. ALL APPLICANTS
have the right to self-determination and capacity to do so is assumed unless otherwise proven.
m m u u s s t t b b e e s s o o u u g g h h t t a a n n d d r r e e c c o o r r d d e e d d . .
His/her preference to stay at home or to be admitted to residential long-term care
Yes
No
Has the personʼs above preference been discussed with him/her?
If YES - brief outline of outcome
________________________________________________________________________________________________________
________________________________________________________________________________________________________
If No - Provide a reason and identify with whom it has been discussed & outline outcome
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Completed by: NAME: ____________________________ Role: ______________ Date: _________ Signature: ______________
(PRINT)
1
COMMON SUMMARY ASSESSMENT REPORT
Please complete all sections clearly in block capitals. Read guidance notes before completing
I confirm that the assessment process and purpose has been explained to me. I consent that information may be
shared as appropriate by relevant health and social care professionals in the processing of this application.
Signature ___________________________________________ Applicant/Specified Person Date ___________________
(Delete as appropriate)
:
1. SOURCE OF REFERRAL (PLEASE TICK)
Community Hospital
Acute Hospital
GP
Mental Health
Community
Nursing Home
Name of Referring Location: _____________________________ Date of Referral: _____________
2. PERSONAL DETAILS:
First Name: ______________________ Surname(s): ______________________ Preferred Name: ______________________
Current Address:
Home/Past Address (If relevant):
Tel No(s):
_________________________________
_________________________________
______________________________
_________________________________
_________________________________
Date of Birth (DD/MM/YYYY)
Medical Card No: ___________________
Hospital Number:___________________
______________________________
PPS No. : ________________________________________________________________________________________________________
3. PERSONAL CIRCUMSTANCES:
Marital Status:
Single
Married
Widowed
Separated
Divorced
Other
Living Circumstance:
Alone
With Spouse
With partner
With family
With carer
With Other
Describe Housing situation (See guidance document):
Who is the Principal Carer: _______________________________________________________________________________
What level of support do they provide?
(Please include contact details):
Assessment of Carerʼs needs completed?
Yes
No
(Please attach if available)
Identify any family members, neighbours, friends who provide support:
Contact Person/Specified Person/Care Rep: _______________________________________
Relationship to applicant?
(Contact details address/phone/mobile):
_______________________________________
__________________________
___________________________________________________________________________
GP: _________________________________________________
Contact Details: _________________________________
PHN &/or CMHN: ______________________________________
Contact Details Health Centre: _____________________
4. ALL APPLICANTS
have the right to self-determination and capacity to do so is assumed unless otherwise proven.
m m u u s s t t b b e e s s o o u u g g h h t t a a n n d d r r e e c c o o r r d d e e d d . .
His/her preference to stay at home or to be admitted to residential long-term care
Yes
No
Has the personʼs above preference been discussed with him/her?
If YES - brief outline of outcome
________________________________________________________________________________________________________
________________________________________________________________________________________________________
If No - Provide a reason and identify with whom it has been discussed & outline outcome
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Completed by: NAME: ____________________________ Role: ______________ Date: _________ Signature: ______________
(PRINT)
1
CS R pplicant’s Name _______________________________________________ DOB ___________________
5. RECORD OF CURRENT COMMUNITY/HOME SUPPORT SERVICES
(See Guidance Document before completing):
SERVICE
Home
Day
Aids and
(Tick)
Help/Support
Care
Respite
Meals Supply
Laundry
Appliances
Hours/Times p/w or
relevant time or if
refused services
SERVICE
PHN/CMHN
Family support/
Therapy or
Services
(Tick)
Private Carer
other discipline
Day Hospital
Refused
Hours/Times p/w or
relevant time or if
refused services
Completed by: NAME: ____________________________ Role: ______________ Date: _________ Signature: ______________
(PRINT)
6(a). CURRENT DIAGNOSIS AND MEDICAL SUMMARY:
(Please include only relevant conditions)
Completed by: NAME: ____________________________ Role: ______________ Date: _________ Signature: ______________
(PRINT)
6(b). DETAILS OF THE PERSON’S MENTAL HEALTH STATUS:
(Please attach any supporting documentation, if available)
Completed by: NAME: ____________________________ Role: ______________ Date: _________ Signature: ______________
(PRINT)
7. CURRENT MEDICATIONS
(See Guidance Notes - Not for Purpose of Dispensing)
Name of Drug
Dosage
Frequency
Name of Drug
Dosage
Frequency
Completed by: NAME: ____________________________ Role: ______________ Date: _________ Signature: ______________
(PRINT)
2
CS R pplicant’s Name _______________________________________________ DOB ___________________
8: ASSESSMENTS
DATE
DATE
8 (A): BARTHEL INDEX
Please insert Date(s) Undertaken
WEIGHTING SCORE
SCORE SCORE
3
2
1
0
Continent
Occasional Accident
Incontinent
Bowel
(Preceding week)
(Or needs an enema)
(Preceding 24-48 hours)
Continent
Occasional Accident
Incontinent
(Or Catheterised & Unable to Manage)
Bladder
Independent
Needs Help
Grooming
Toilet Use
Independent
Needs Some Help
Dependent
Independent
Needs Some Help
Unable
Feeding
Independent Minimal Help Needed
Major Help
Unable
)
Transfer
(From bed to chair & back)
(1-2 persons) Needed
(No sitting balance
Independent Walks with help of 1 person
Wheelchair Iindependent
Immobile
Mobility
Independent
Needs Help
Dependent
Dressing
(Buttons, zips and laces)
(But can do half unaided)
Independent
Needs Help
Unable
Stairs
(Up & down must carry walking aid)
(Verbal or physical/carrying of aid)
Independent
Dependent
Bathing
(Getting in & out unaided & wash self)
TOTAL
Independent (20)
Low Dependency (16-19)
Medium Dependency (11-15 ) High Dependency (6-10)
Maximum Dependency ( 0-5)
Findings
Completed by: NAME: ____________________________ Role: ______________ Date: _________ Signature: ______________
(PRINT)
8 (B): COMMUNICATION
Tick
Date
Signature
No problems
Retains most information and can indicate needs verbally
Difficulty speaking but retains information and indicates needs non-verbally
Can speak but cannot indicate needs or retain information
No effective means of communication
8 (C): COGNITIVE SCREENING REPORT - BY DATE ORDER IF MORE THEN ONE AVAILABLE
Cognitive Assessment
Date
Result
Signature
Date
Result
Signature
(Specify Screening Tool)
8 (D): OTHER ASSESSMENTS
Result
(Specify Tool Used)
Date
Signature
Pressure Sore Risk
Falls Risk
Nutritional Risk
Wandering Risk
Other - Specify
8 (E): OTHER SIGNIFICANT MEDICAL/SOCIAL/ RISK FACTORS THAT SHOULD BE
CONSIDERED AS PART OF THE CARE NEEDS ASSESSMENT:
Completed by: NAME: ____________________________ Role: ______________ Date: _________ Signature: ______________
(PRINT)
3
CS R pplicant’s Name _______________________________________________ DOB ___________________
9: ADDITIONAL COMMENTS e.g. Employment, Recreational or Social Needs
(Attach supporting documentation):
Completed by: NAME: ____________________________ Role: ______________ Date: _________ Signature: ______________
(PRINT)
10(a). HEALTH PROFESSIONAL REPORTS.
(Please attach if relevant. Tick to indicate a report is appended)
Nursing
Dietician
Occupational Therapy
Speech and Language
Other
Physiotherapy
Psychology
Podiatry
Social Work
10(b). SPECIALIST ASSESSMENT
(Best practice recommends that all older people should have a Consultant Geriatrician/Old Age Psychiatry
assessment prior to a decision being made about their future care needs.)
Signature:
Geriatric Medicine
Completed
Date:
Signature:
Old Age Psychiatry
Completed
Date:
Signature:
Rehabilitation Consultant
Completed
Date:
Signature:
Neurologist
Completed
Date:
Other(Specify)
Signature:
Completed
Date:
Specialist Comment:
(Or append report)
Completed by: NAME: ___________________________ Specialty: _____________ Date: _________ Signature: ____________
(PRINT)
11. RECOMMENDATION BY MDT. For Completion by MDT. See Guidance Notes
It is the recommendation of this MDT that this personʼs overall care needs are currently best met within a Long Term Residential Care Setting (Please Tick):
Yes
No
Confirmation of MDTʼs Recommendation
Confirmation of MDTʼs Recommendation
Name: ____________________________________________________
Name: ____________________________________________________
Role: ______________________________ Date: __________________
Role: ______________________________ Date: __________________
Signature: _________________________________________________
Signature: _________________________________________________
Name & Signature of Professional Co-ordinating completion of this CSAR Form
NAME: _________________________________ Role: ______________ Date: _________ Signature: _____________________
(PRINT)
12. LPF DETERMINATION OF CARE NEEDS
FOR COMPLETION BY LPF ONLY
It is the determination of this LPF that this personʼs overall care needs are currently best met by:
(Please Tick)
Additional Information
Long Term Residential Care Setting
Sheltered Housing
Other (Specify)
At Home with Community Supports
Likelihood of change in personal circumstances
Low Risk
Medium Risk
High Risk
Confirmation of LPFʼs Determination
Confirmation of LPFʼs Determination
Confirmation of LPFʼs Determination
Name: ________________________________
Name: ________________________________
Name: ________________________________
Role: ________________ Date: ____________
Role: ________________ Date: ____________
Role: ________________ Date: ____________
Signature: _____________________________
Signature: _____________________________
Signature: _____________________________
IF LONG TERM CARE IS NOT DETERMINED TO BE APPROPRIATE-THE FOLLOWING SERVICE(S) ARE RECOMMENDED BY LPF
Home
Day
Meals
Aids/
Service
Help/Support
Care
Respite
Supply
Laundry
Appliances
Recommended
PHN/CMHN
Therapy or other
Day
Other
Other
discipline
Hospital
(Specify)
(Specify)
Comment(s)
4