Wheelchair and Seating Prescription Request Form
Contents
1. London NW10 7AW Tel 0845 045 0194 Fax 0208 965 9672 Hours of Work 8 00 am to 5 00 pm Monday to Friday Repair Service available 8 00 am 5 00 pm Monday to Friday There is an out of hour s service operating in the evenings and weekends e The Wheelchair Service is only responsible for repairs relating to normal wear and tear of your equipment e The equipment must not be repaired by anyone other than the Repair Contractor NRS e All work carried out by the Repair Contractor will be paid for by the Wheelchair Service However the Wheelchair Service is not responsible for costs of repairs through misuse or negligence Central London Community Healthcare NHS Trust provides quality care for people in their homes and communities Page 10 of 12 Chairman Pamela J Chesters September 2013 Chief Executive James A Reilly e The Repair Contractor will come to your home or other appropriate venue Day Centre School etc to carry out repairs e f your wheelchair has to be removed by the Repair Contractor for completion of repairs at their factory we may be able to provide you with a temporary replacement wheelchair This wheelchair will only be a standard model and will not necessarily be the same model or size as your own issued wheelchair Maintenance Service available e f you have an Electric Powered Indoor or Indoor Outdoor Wheelchair EPIC or EPIOC the Repair Contractor NRS is responsible for carrying out an ann2. Max of 4 15 High risk Scores can be discounted after 48 hours provided patient is recovering normally 20 Very high risk TT OCOOAWNwOrY 00 www judy waterlow co uk History of pressure sores past and present pressure management equipment techniques eeeeeeeeeseeeeeeeneeeeeeeees Central London Community Healthcare NHS Trust provides quality care for people in their homes and communities Page 4 of 12 Chairman Pamela J Chesters September 2013 Chief Executive James A Reilly Posture Note NAD no abnormality detected Neutral Oblique O Rotated O Anterior Tilt O Posterior Tilt Low Tone Other comments observations Measurements Body Dimensions Note measure in sitting using a straight or rigid tape measure Height Weight essential A Hip Width B Upper leg length L R C Lower leg length L R D Height of scapular inferior angle E Elbow height L R Other Wheelchair Requirements Less than 6 months O More than 6 months Frequency of use O Less than 1 day week O 2 3 days week Length of time sitting Less than 3 hours C More than 3 hours Po Equipment on Issue or Trialled C Issued Trialled Supplied by Any issues problems with the current wheelchair Details and
3. be used Build Weight Skin Type Sex Malnutrition Screening Tool MST for Height Visual Risk Age Nutrition Vol 15 No 6 1999 Australia Areas Average A Has patient lost B Weight loss score BMI 20 24 9 0 Healthy 0 Male 1 weight recently 0 5 5kg 1 Above average Tissue paper 1 Yes Go to B 5 10kg 2 BMI 25 29 9 1 Dry 1 Female 2 No Go to C 10 15kg 3 Obese Oedematous 1 Unsure Go to C gt 15kg 4 BMI gt 30 2 Clammy temp 1 14 49 1 and Unsure 2 Below average Discoloured 2 50 64 2 score 2 BMI lt 20 3 grade 1 65 74 3 C Patient eating poorly Nutrition Score Broken spots 3 75 80 4 or lack of appetite If gt 2 refer for nutrition BMI Wt kg Ht m grade 2 4 81 5 No 0 Yes Score 1 assessment intervention Continence Mobility Special Risks Complete Tissue Malnutrition Neurological Deficit catheterised 0 Seals Ifid a Terminal cachexia 8 Diabetes MS CV A 4 U neincontinence A p idgety 2 Multiple organ failure 8 Motor sensory 5 Restricted 3 Single organ failure 5 Paraplegia Max of 6 6 f resp renal cardiac Major Surgery or Trauma Faecal incontinence 2 Inert traction 4 Peripheral vascular disease 5 i Chair bound 5 Anaemia Hb lt 8 2 Orthopaedic Spinal 5 Double incontinent 3 e g wheelchair Smoking 1 On table gt 2 hrs 5 On table gt 6 hrs 8 SCORE SCORE TOTAL Medication Cytotoxics long term high dose steroids 10 At risk Anti inflammatory
4. outcome of any wheelchair equipment trialled Central London Community Healthcare NHS Trust provides quality care for people in their homes and communities Page 5 of 12 Chairman Pamela J Chesters September 2013 Chief Executive James A Reilly Goals for Wheelchair and Seating Provision Note Ensure all goals are specific measureable achievable realistic and timed SMART Client Goals Assessor Goals Problem Solving Summary Note All identified risks must be documented and managed e g stability pressure posture access medical etc Issues risks discussed Possible solutions Safeguarding issues O No O Yes Discuss Additional Information Central London Community Healthcare NHS Trust provides quality care for people in their homes and communities Page 6 of 12 Chairman Pamela J Chesters September 2013 Chief Executive James A Reilly Equipment Requested Note Provision of more complex equipment will require assessment by the Specialist Wheelchair Services Manual C Self propel S P O Attendant propel A P Wheelchair Mandatory O 15 x16 O 16 x16 O 17 x17 O 18 x17 Flat standard foam low risk C Flat memory foam medium risk Contoured medium risk Cushion e g Community One e g Lowzone Flat memory foam high risk L Contoured high very high risk e g Sunmate or Super Cont
5. the Wheelchair Service if you change your address If you move out of area your equipment may be taken with you Please inform us of your forwarding address so that we can transfer your notes to your new Wheelchair Service e You must also inform the Wheelchair Service if you move into a Nursing or Residential Home e You must also inform the Wheelchair Service if you intend to leave the country for any period of time exceeding 90 days e f you take the equipment oversees on holiday you are advised to take out insurance as the user is responsible for the cost of any loss or damage incurred abroad Section 2 Adverse Incidents Wheelchairs and associated equipment are defined as Medical Devices An adverse incident is an event which causes or has the potential to cause unexpected or unwanted effects involving the safety of users or other persons It is important to identify what may constitute an adverse Incident All Adverse Incidents must be reported to the Medicines amp Healthcare Products Regulatory Agency MHRA If you feel that an accident incident has occurred which constitutes an adverse Incident you must contact the Wheelchair Service immediately and they will give advice on appropriate action to take Section 3 Repairs For repairs to Manual amp Electrically Powered Indoor Chairs EPIC and Electrically Powered Indoor amp Outdoor Chairs EPIOC Nottingham Rehabilitation Supplies NRS 4 McNicol Drive Park Royal
6. Central London Community Healthcare NHS NHS Trust Barnet I Hammersmith and Fulham I Kensington and Chelsea I Westminster Wheelchair and Seating Specialist Wheelchair Services Prescription Request Form This form can only be completed by an Occupational Therapist or Physiotherapist All sections of this form must be completed for the prescription to proceed Equipment will only be provided for individuals who meet the eligibility criteria for provision Please provide this Prescription Request at least 2 weeks before the wheelchair and seating is required Final provision is at the discretion of the Specialist Wheelchair Services EQUIPMENT WILL NOT BE ISSUED PRIOR TO RECEIPT OF THE CONDITIONS OF LOAN FORM THE PRESCRIBING THERAPIST IS REQUIRED TO HAND OVER ANY EQUIPMENT PRESCRIBED SOUP PUE eS Personal Details Title Mr Mrs Ms Miss Mstr Other Preferred method of contact GP Name _ Practice Address Post Code Telephone No Next of Kin Nominated Contact Person Recah Telephone no Telephone no Power of Attorney O N A LPA Finance Property CO LPA Health Welfare Details Children Primary Carer Person with Parental Responsibility Is this child subject to safeguarding plan YES Central London Community Healthcare NHS Trust provides quality care for people in their homes and communities Page 1 of 12 Chairman Pamela J Chesters September 2013 Chief Executive James A R
7. Rehabilitation Supplies NRS Once the order has been raised by the Specialist Wheelchair Service NRS will be instructed to contact the external therapist to arrange delivery of the equipment If you have any queries relating to delivery of equipment please contact NRS directly Tel 0845 045 0194 Central London Community Healthcare NHS Trust provides quality care for people in their homes and communities Page 8 of 12 Chairman Pamela J Chesters September 2013 Chief Executive James A Reilly Central London Community Healthcare NHS NHS Trust Barnet I Hammersmith and Fulham I Kensington and Chelsea I Westminster Specialist Wheelchair Services Terms amp Conditions of Loan Service User Ref No Section 1 User Responsibility All equipment provided by the Wheelchair Service remains the property of the National Health Service NHS and is loaned to you under the following conditions e Your details are automatically shared with our database providers Soft Options and Approved Repairers Nottingham Rehabilitation Supplies NRS e Itis for your use only and must not be used by anyone else or for any other purpose other than that for which it was provided e Itis your responsibility to use the equipment safely as instructed by the Wheelchair Service and the manufacturer s user manual e The equipment must be kept clean and maintained in good order Any faults or problems should be reported to the Maintenance amp Repair Co
8. a ee eee een Eo al gt a EE AE EE A E Pa eo A Supplementary oxygen required O No Yes detailsi Xes eere a ae ee ee eee on rere SULGErY pastplanned srren Onicha e ieee eee History of falls seserian a eee aE E EEE E aL EE E EE E EE History of pain cersieineisiorisan rra aeaa r oa a a e a aa aaa aa arae Ta iS Pressure area grade location ccccccceeeeeessssececeeeeeeeeeeeesaaeeeeeeeeeeesaaaaeaeeeseeeeeeeaaaaaaeeeeeeeeeeeeeseaeaees Any other alerts behaviour substance use MRSA etc eeeeeeeeeeesseeeeeeesesssessssteeeeseeseseneeeaes Is the individual medically unfit to travel in transport O No O Yes details 0 0 0 eee Contraindications for self propelling i e respiratory heart or arthritic conditions cognitive issues Note If requesting a self propelling wheelchair with existing contraindications please request an additional Medical Advice Form for Self Propelling to complete in addition to this form Mobility and Transfers state aides used assistance required and distance BVI TAO heiir aaaeeeaa E aeea ara AEE e e AER eee eee Ee ioi ARANESE Mobility outdoors acad cacasecceossececeaantereracecctcnnssienchauasscequesesuadsasceecusatnsenssunes e5sateecedaaserwnqeasomiaccrascausaten Sitting balance C Independent Short periods O With assistance Dependent Transfers Independent O Assistanc
9. e of 1 Assistance of 2 Transfer aides TI Nil O Slide board O Rota stand UC Hoist O Other nesses Central London Community Healthcare NHS Trust provides quality care for people in their homes and communities Page 3 of 12 Chairman Pamela J Chesters September 2013 Chief Executive James A Reilly Social Support and Care Family Friend O Formal Paid D Times per day Carers for Does the carer have any difficulties Folding a wheelchair O YES NO Lifting a wheelchair in out of a car O YES NO Pushing a wheelchair O YES O NO Fitting accessories to wheelchair O YES O NO Other Accommodation House C Maisonette C Bungalow Residential NH O Flat Floor Lift Access O Yes O No Tenure of property Owner C Council Housing C Private rental Access Sufficient circulation space indoors O Yes O No Sufficient door way width LI Yes O No Steps No Yes Details How Many eeeeeeeeteereeeees Other Is appropriate static seating lounge chair in place DO Yes No If not has a referral been made for this O Yes 1 No To whom Waterlow Pressure Ulcer Prevention Treatment Policy Note Ring scores in table then add and score total More than one score per category can
10. eilly Patient s Equal Access Form Why we need you to complete this form We have a legal duty to ensure that patients accessing our services are treated fairly Please complete this form to help us comply with our duty Ethnicity Please indicate your ethnic background by ticking one box below M This would assist to identify earlier treatment for certain illness such as diabetes or high blood pressure which may affect some patients more than others White Asian or Asian British O British Eng Scot Welsh O Indian O Irish O Pakistani O Other White Background O Bangladeshi Please specify sciccncsasccccaseceeseesdecescisneniens O Other Asian Background Mixed Please SPOOMY cwcsccccscscienssccicnecereateaczeeeennes O White and Black Caribbean O White and Black African O White and Asian O Other Mixed Background Please specify 2 2 ccceeeceeeeeececeeeeeeeeeees Black or Black British O Caribbean O African O Other Black Background Please specify csceceeeeeeeeeeeeeeeeeeeeees Other Ethnic Groups O Chinese O Any other ethnic group Please specify 0 0seecececeeeeeeeeeeeeeeeeeeees O Declined to disclose refused Do you speak English O Yes No Do you need a qualified interpreter 1 Yes C No If yes please indicate which language cccceeeeeeeeeseneceeeeeeeeeeeeeaaeaeeeeeeeeenenaaaeaeeeeeeeeeseeesaaaees What is your preferred langua
11. ge xcscccscicte de 2c Shtecetie fei ca chcaitce Ofek dates eade addict adage ede 1 What is your smoking status tick one box only M Never smoked L Thanks you do not need to answer question 2 Ex Smoker L Thanks you do not need to answer question 2 Current smoker O Please answer question 2 2 If you currently smoke would you like to be offered a referral to our Stop Smoking team O Yes O No Central London Community Healthcare NHS Trust provides quality care for people in their homes and communities Page 2 of 12 Chairman Pamela J Chesters September 2013 Chief Executive James A Reilly Reason for Referral please state Medical Condition s J Improving O Stable CO Deteriorating Rapidly Deteriorating Diagnosis and Past Medical History Is the wheelchair essential for discharge O N A O No LO Yes Discharge Date Note Wheelchairs are only considered essential for discharge by the Specialist Wheelchair Services where provision will enable the person to be independent of carers Medical Background Medication including doses aerecicncsctessencccapceniesnvasne soot dendatasetbaadoce secdatasabadtbabsecianensaaaciorsuacorananeiceaaacen Allergies E No UVSC TAS Ses ceicestesote tach c var tn bacetetes ateo atara aeaea aa r ioaiten COUN oes cance ce Pee cet catch ae oe ca eek eee cee eae ee teehee eee cae oe ee eae ec 6 ae ee eee ae eee Ee
12. heelchair Services LI acknowledge that final prescription is at the discretion of the Specialist Wheelchair Services Signed sili nee Wile a sa ee eee ale Assessor Name cceeee cence eee tenes Designation 082005 06 cts Rettig eee Date uier att sade chosenags ade dete ieeaetea abet Work Location a nn enneren nennen PHONG E E EE A E at cecdhehas rial orna e A eae PAM a tetas arts arenes Central London Community Healthcare NHS Trust provides quality care for people in their homes and communities Page 7 of 12 Chairman Pamela J Chesters September 2013 Chief Executive James A Reilly Please Return this Form to Central London Specialist Wheelchair Services Covering Westminster Kensington and Chelsea and Hammersmith and Fulham Direct Duty contact for therapists only Tel 0208 962 3932 Daily 9am to 12pm Email Duty Therapist clch nhs uk 306 Kensal Road London W10 5BE Tel 0208 962 3939 Fax 020 8962 3965 Email clcht wheelchairs nhs net Central London Specialist Wheelchair Services Barnet Covering Barnet Direct Duty contact for therapists only Tel 0845 389 2889 Monday Wednesday Friday 9am 12 30 Email Barnet Duty Therapist clch nhs uk Edgware Community Hospital Ground Floor Deansbrook House Burnt Oak Broadway Edgware HA8 OAD Tel 0845 389 2889 Fax 0208 349 7435 Email CLCHT barnetwheelchairservice nhs net Approved Repairers Nottingham
13. nstrate the footrest mechanism and adjust to suit How to release and replace the armrests How to enter and leave the wheelchair How to operate the brakes Demonstrate removal and refit of Quick Release Wheel if fitted Adjust lap strap and demonstrate operation Demonstrate how to manoeuvre the wheelchair up and down kerbs Adjust to suit and demonstrate any other equipment AE EH E J EAEE Handover manufacturer s user handbook to Client or representative Signature Service User Representative Print NAME of Service User Representative Relationship Name of Clinician Signature of Clinician Date Central London Community Healthcare NHS Trust provides quality care for people in their homes and communities Page 12 of 12 Chairman Pamela J Chesters September 2013 Chief Executive James A Reilly
14. ntractor NRS e lf you have a powered chair you must look after the battery as shown in the instructions given with the chair Good ventilation is needed when charging the battery to avoid a build up of harmful gases e No alterations or attachments may be made to the equipment without prior agreement from the Wheelchair Service This includes the fitting of third party equipment such as power packs which may invalidate the manufacturers warranty In situations where this is done without prior consent from the Wheelchair Service the wheelchair may be removed permanently and any subsequent repair costs passed on to the Service User e Itis advisable that you inform your home insurers to amend your policy to include the wheelchair and accessories or alternatively take out insurance to cover your wheelchair and accessories e If the equipment is no longer required for any reason you must inform the Wheelchair Service Arrangements will then be made for it to be collected It must not be disposed of in any other way or given to anyone other than the Wheelchair Service or Repair Contractor e You must inform the Wheelchair Service immediately if any or the equipment is o Lost or stolen o Involved in an accident o Damaged Central London Community Healthcare NHS Trust provides quality care for people in their homes and communities Page 9 of 12 Chairman Pamela J Chesters September 2013 Chief Executive James A Reilly e You must also inform
15. our e g Flotech Solution Note Pressure risks needs to account for frequency and duration of use in addition to identified clinical risks C Qbitus back with lateral supports O Qbitus crescent infill back 112 Backrest C Jay Lumbar Support C Anti tippers Rear wheels set back C Stump board O Left O Right O Qbitus Unifit armrests C Bexhill armrest Left O Right O Angle adjustable footplates Accessories C Extended brake levers O Left O Right O Oxygen carrier and Footboard only available with standard foot plates Modifications Depth 08 O 10 0O12 Note Prescription request of an O2 cylinder holder is only permitted for palliative cases where an O2 Medical Advice Form please request has been completed returned by the O2 prescriber A Specialist Wheelchair Service RE may also be required to accompany handover Prescribing Therapist s Details please tick to indicate acceptance of the following statements The service user is aware this referral is being made have completed this assessment form truthfully and accurately LI have attached a signed Terms and Conditions of Loan form and provided a copy to the Service User _ agree to complete the handover of the wheelchair and seating LI Following handover agree to forward the completed Handover Certificate to the W
16. ual service on it You will be contacted by them to arrange a time for this service to take place e At the present time there is a facility for Servicing of manual wheelchairs You will be informed accordingly by the Wheelchair Service at the time of provision if planned preventative maintenance PPM is recommended for the particular items issued to you SPECIFIC INSTRUCTIONS FOR USE agree to accept the wheelchair prescribed for me by the Wheelchair Service under the Conditions of Loan described above Signed Name Please print Signature of Therapist Name Please print Date Central London Community Healthcare NHS Trust provides quality care for people in their homes and communities Page 11 of 12 Chairman Pamela J Chesters September 2013 Chief Executive James A Reilly Central London Community Healthcare NHS NHS Trust Barnet I Hammersmith and Fulham I Kensington and Chelsea I Westminster Handover Certificate For Non Powered Wheelchairs Specialist Wheelchair Services SERVICE USER NAME MANUFACTURERS WHEELCHAIR NO SERVICE SERIAL NO SERVICE USER NO CHAIR MODEL CHAIR SIZE COLOUR OTHER SEATING ACCESSORIES The Clinician is to demonstrate to the Service User and Representative as appropriate the following please indicate in the box with a tick when the task has been completed How to open and fold the wheelchair s How to fold the back rest Demo
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