Referral to the Worcestershire Community Stroke Service

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Referral to the Community Stroke Service

All patients must be referred using this form.

For mild strokes/routine follow-up please complete part A only.

For ESD/complex patients (residential home, nursing home, or patients with a package of care) please complete parts A and B.

Part A

Note: Questions marked by * are mandatory

*This is a mandatory field. Has the patient consented to this referral?

Yes
No

*This is a mandatory field. Patient's name

*This is a mandatory field. Full address

*This is a mandatory field. Patient's contact details

*This is a mandatory field. Date of birth

If you answered any other ethnic group, please comment here

*This is a mandatory field. NHS number

*This is a mandatory field. GP name

*This is a mandatory field. GP surgery details

*This is a mandatory field. Date of stroke

	Yes	No
Thrombolysis?
Thrombectomy?

Investigations still required

Investigation for AF requested?

72 hr tape
Zio

*This is a mandatory field. Clinical diagnosis

*This is a mandatory field. Scan results

*This is a mandatory field. Stroke confirmed?

Yes
No

*This is a mandatory field. NIHSS on admission

*This is a mandatory field. NIHSS on discharge

Modified Rankin score at discharge

Rockwood frailty score pre-stroke

*This is a mandatory field. Medical history

Lives with

Alone
Spouse
Other

Please include details on the above, if you answered 'other'

Lives in

House
Bungalow
Flat
Other

Please include details on the above, if you answered 'other'

	Yes	No
Key safe required?
Key safe in situ?

Key safe number

	Yes	No
Pendant alarm required?
Pendant alarm in situ?

*This is a mandatory field. Next of kin/first contact name (write NA if none)

*This is a mandatory field. Telephone number (write NA if none)

*This is a mandatory field. Next of kin/first contact name's relationship to patient (write NA if none)

*This is a mandatory field. Details of care provider (if applicable, write NA if none)

How many care calls per day are they receiving (if applicable, write NA if none)?

Cognition screen

Cognition screen score

Mood screen

Mood screen score

	Yes	No
ReSPECT form in situ?
DNACPR in place?

*This is a mandatory field. Estimated discharge date

To be discharged from (ward, unit, service etc.)

*This is a mandatory field. Patient goal 1 - Describe the patient's primary goal or expectation from treatment or referral.

*This is a mandatory field. Patient goal 2 - Outline a secondary goal the patient hopes to achieve.

*This is a mandatory field. Patient goal 3 - Include any additional expectations or long-term goals.

*This is a mandatory field. Referrer's full name

*This is a mandatory field. Email address for referrer

*This is a mandatory field. Telephone number for referrer

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Referral to the Worcestershire Community Stroke Service

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Referral to the Community Stroke Service

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