Intermediate Care Bed Base Referral

Bed Base Referral

Initial questions
Patient demographics
If contact details are incorrectly input where mandatory the referral cannot be processed
Overseas visitor?
Consent gained?*
Smoker?*
Patient has consented to the referral being made?*
Next of Kin
Tick as appropriate:*
Referrer details
If contact details are incorrectly input where mandatory the referral cannot be processed
Only to be completed if referring from community
Therapy
Is the patient being discharged with any appliances e.g. leg brace or collar?*
Does the patient have a non-weight bearing status?*
Specialist Nurse Involvement?
Psychological wellbeing
Infection Risk Assessment
Does the patient have any of the following infections:*
Carbapenemase–Producing Enterobacteriaceae (CPE)
Has the patient been an inpatient in a hospital abroad or received dialysis abroad?*
See list of high risk countries at Appendix B in Multi resistant organism policy.
Has the patient had an infection or been previously colonised or in contact with anyone with CPE?*
Pressure area/skin assessment
Fluid & Nutrition
Elimination
Locala Intermediate Care Beds do not provide continence products
Pain
Current Medication
If yes, please administer on the day of discharge prior to transfer
Any other comments
If you do not receive an email acknowledgement your referral has not been submitted. Please check that all details are correct, mandatory fields completed and re-submit.