Information required

If contact details are incorrectly input where mandatory the referral cannot be processed

Patient name *

Address *

Date of birth *

Phone number *

NHS number *

Overseas visitor?

Yes

What is the patient’s main spoken language? *

Is an interpreter needed? *

Yes

Are there any communication needs for this patient or their parent/carer? For example, related to learning disabilities or autism or due to impaired sight/ hearing or any other reason/s. *

Yes

Are there any communication needs for this patient or their parent/carer? For example, related to learning disabilities or autism or due to impaired sight/ hearing or any other reason/s. *

Yes

What might be helpful when communicating with this patient or their parent/carer?

Name of consultant/referrer *

Referrer email *

Referrer contact no *

Referral from *

Patient has consented to information sharing? *

Yes

Patient has consented to the referral *

Yes

If patient is unable to consent to referral, please provide details *

Best interest decision made by (Name) *

Best interest decision made by (Phone number) *

Referral

Referral made for trial without long term catheter and of teaching Intermittent Self Catheterisation (ISC) *

Yes

Please provide the reason why ISC is required *

Please note we do not take referrals for teaching ISC prior to surgical procedures

Incomplete bladder emptying *

Yes

Stricture therapy *

Yes

Urethral Dilation *

Yes

Please provide details of the patient’s long term treatment plan *

Please provide details of how frequently the patient is required to perform ISC *

Please provide details of any follow up care to be provided by acute services *

Has the patient been provided with verbal and written advice regarding ISC as a treatment option *

Yes

Does the patient understand and consents to using ISC as a treatment option *

Yes

Does the patient have the dexterity, capacity and willingness to self-care *

Yes

Will the patient require support from a carer to perform ISC *

Yes

Does the patient have a carer willing to support them with performing ISC *

Yes

Has the reason for referral been explained to the patient? *

Yes

If no, please ensure the patient is fully informed prior to discharge.

Has the procedure of CISC been explained to the patient? *

Yes

If no, please ensure the patient is fully informed prior to discharge.

Has the patient been provided with a written guide to CIS? *

Yes

If no, please ensure the patient is fully informed prior to discharge.

Teaching of Intermittent Self Catheterisation