Kirklees Independent Living Team (KILT)

Expected outcomes

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

GP Surgery

Next of Kin

Additional Contact

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

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

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