Community Care Access Referral - Alberta Health Services

1 Community care Access Referral All fields in bold must be completed along with any other applicable fields. Once competed fax to Last Name Referral Information Date Referral Initiated (yyyy-Mon-dd). First Name Middle Initials Date Admitted to Acute care (yyyy-Mon-dd). Personal Health Number Discharge from Acute care (yyyy-Mon-dd). Date of Birth (yyyy-Mon-dd) Age Acute care Site Acute care Unit #. Permanent Address Location of initial visit Referred by ( Physician office, self). (Street). Phone (City) (Postal Code). Home Phone Work Phone Current Active Diagnoses 1). Current Address Same as above Location of initial visit 2). (Street) 3). (City) (Postal Code). Aware of Diagnoses Aware of HC Referral Home Phone Work Phone Client Client Rural Tax District Family Family Name of Community care Physician (last, first). Gender Male Female Marital Status Single Married Common-law Fax Phone Separated Divorced Widowed Language Other Physician (last, first) Other Physician Phone 1st 2nd Interpreter Required No Available No Caregiver / Contact Primary Caregiver No Yes Yes Yes Name of Interpreter (last, first name).

2 Interpreter Phone Relationship to client Residence Type (circle number). 1 Private Home, Condo, Apartment 2 Lodge Phone (home). 3 Personal care Home (work). 4 Private Assisted Living (cell). 5 Long Term care 6 Group Home For Transition Services Use Only 7 Hotel/Motel Date of Initial Visit (yyyy-Mon-dd). 8 Shelter 9 Other (specify) PARIS ID #. Living Arrangements (circle number) Community 1 alone 4 with others 2 with spouse 5 group setting HC Team ( SC, SN). 3 with child 101317(Rev2014-04) Page 1 of 3. Name (last, first). Community care Access Referral Reason for Referral History/Presenting Problem Date (yyyy-Mon-dd) Weight (kg) Blood Pressure Heart Rate Temp Resp Caregiver Coping N/A Yes No (specify). Safety of Client (check all that apply) Safety of Staff (check all that apply). None Not Known No Identified Risk Allergies (specify) Pet(s) (specify). Fall risk Known active substance abuse (check and specify Home environment those that apply). Smoking in the home Alcohol Altered cognition (specify) Narcotics Lack of equipment in home (specify) Street drugs Other Power Dependent No Yes Other Behavioural concerns of client (specify).

3 Infectious Disease History None Not Known Behavioural concerns of others (specify). C Difficile ARO HIV+. Hepatitis TB. Other (specify) Other safety concerns ( weapons). Uncontrolled drainage/diarrhea (specify). URI. Name of Others Currently Involved in care Phone Name of Ambulatory Clinic/Program Phone 101317(Rev2014-04) Page 2 of 3. Name (last, first). Community care Access Referral Professional Services and Support Required Assessment for Supportive care Exercise Program Assess Support Surface Chronic Disease Management Pain Management (with Cognitive Retraining Edema Management Modalities) Energy Conservation Environment Assessment for Extremity Edema Environmental Adaptation Caregiver Safety Management / Lower Leg Feeding / Swallowing Medication Management Assessment Safety in Home Pain/Symptom Management Gait / Balance Small ADL Equipment Respiratory care Respiratory Rehabilitation Large ADL Equipment ( lifts). Wound care Walking Aids / Mobility Other Services that require Physician Orders Advance care Planning Acute Ortho Follow-up Orders attached Personal Directive Catheter Change/ care Orders attached No Yes Home Parenteral Therapy Orders attached Injections Orders attached Goals of care Parenteral Nutrition (TPN) Orders attached No Yes Peritoneal Dialysis (CAPD) Orders attached Referral Information Completed by Name (last, first) Discipline (RN, SW, OT, PT, Other).

4 Signature Date (yyyy-Mon-dd). Department /Program/Agency Is there a need for Home care staff to contact you directly? No Yes Phone Pager 101317(Rev2014-04) Page 3 of 3.