Services

Kirklees Independent Living Team (KILT)

Mental Capacity and Best Interest Decisions
            Referral Details

                      Expected outcomes

                      Please include goals and expectations e.g. to be able to make microwave meals, wash and dress independently, mobility goals.

                          Service referral
                              Service user initial information

                                                          GP Surgery

                                                                  Next of Kin

                                                                                Additional Contact

                                                                                            Medical information

                                                                                            Current Medical Problem

                                                                                            Including investigations, diagnosis, treatment and therapy assessments, any falls in the last 48 hours

                                                                                              Medical History

                                                                                               

                                                                                              Please give details of past medical history relevant to this admission, any known allergies including any long-term conditions:

                                                                                                           

                                                                                                          Any other infection control issues?

                                                                                                          Please consider ESBL, C.diff etc.

                                                                                                                     

                                                                                                                    Please describe level of support

                                                                                                                    eg. Physical, verbal etc

                                                                                                                      Are there any medications that are timebound?

                                                                                                                      e.g. parkinsons, diabetes

                                                                                                                        Current method of dispensing

                                                                                                                        eg. original boxes, blister pack, automated dispenser etc.

                                                                                                                          Known Allergies

                                                                                                                           

                                                                                                                          If the service user has any known allergies inc drug allergies, please give details (including the impact on daily living)

                                                                                                                                           

                                                                                                                                          Any Current Needs?

                                                                                                                                          e.g. falls, mobility, nutrition, equipment etc

                                                                                                                                           

                                                                                                                                            Summary of Social Situation

                                                                                                                                            Please include previous situation.

                                                                                                                                            Home Environment Description

                                                                                                                                            Including access, stairs, care phone

                                                                                                                                              Previous Function

                                                                                                                                              e.g. washing and dressing, mobility inc transfers, diet and fluids, toileting etc

                                                                                                                                                          If the service user/patient requires support at home
                                                                                                                                                                      Initial Assessment & Support Planning

                                                                                                                                                                      Support needed for daily functional tasks

                                                                                                                                                                      Please include support needed with daily functional tasks

                                                                                                                                                                       

                                                                                                                                                                      Communication

                                                                                                                                                                      inc. if wears glasses or hearing aid, are they able to communicate?

                                                                                                                                                                           

                                                                                                                                                                          Toileting

                                                                                                                                                                          inc. if service user has colostomy or catheter

                                                                                                                                                                            Skin Integrity

                                                                                                                                                                            any pressure sores, wounds, creams or pressure relieving equipment

                                                                                                                                                                              Nutrition

                                                                                                                                                                              Meal prep, assistance with feeding

                                                                                                                                                                                Mobility/Movement and Handling

                                                                                                                                                                                Provide details of any equipment in place or awaiting delivery

                                                                                                                                                                                           

                                                                                                                                                                                          Existing support networks (formal and informal)

                                                                                                                                                                                          Please include who does the shopping etc.

                                                                                                                                                                                                Please provide details of the best time (s) to contact you

                                                                                                                                                                                                        Other Times

                                                                                                                                                                                                        ie. Night support