UR:Add Label, or details below*XX 146B*Referral to Victorian Acquired Brain Injury (ABI)Rehabilitation Services (inpatient)REFERRAL PROCESSThe Victorian ABI Rehabilitation Services at Alfred Health & Austin Health are state-wide services that provide rehabilitation for people with anAcquired Brain Injury. The two Victorian ABI Rehabilitation Services will work closely together to determine the most suitable service to assess thepatient and the most suitable bed for the patient. Both services accept public patients. Caulfield Hospital also has services for severely injured compensable TAC/ VWA patients. Note: OnlyCaulfield Hospital can accept referrals for patients with tracheostomies. Both services accept referrals for patients with an ABI from traumatic and non traumatic causes (hypoxic, stroke, other non- progressive causes) This referral is to be used by health professionals to refer to the Victorian ABI Rehabilitation Services at Alfred Health (Caulfield Hospital) orAustin Health (Royal Talbot Rehabilitation Centre) only. For routine referrals to subacute rehabilitation please follow the subacute referral processes. If you are not sure where a patient is best referredcontact your local subacute rehabilitation assessment service Referrers will be contacted within 1 business day of receipt of referral. More information may be sought to determine suitability of the patientand where further assessment of the patient is required by the ABI Rehabilitation Service this will occur within 3 business days to determine anoutcome.Attach photocopies of the following (if available): Allied Health AssessmentsPsych, neuro psych notesServiceReferred to Alfred Health Austin HealthRelevant imaging and pathologyWestmead WMPTAS Current medication and obs chartTracheostomy Suction Chart (if applicable)Return completedReferral toAddressContact NumberCaulfield Hospital260 Kooyong RoadCaulfield VIC 3162Fax: 03 9076 [email protected] TalbotRehabilitation Centre1 Yarra BoulevardKew VIC 3101Fax: 03 9490 7523Rehab and Aged Care Assessment ServicePh: 03 9076 6575 or 0419 770 uired-brain-injury-rehabilitation/ABI UnitPh: 03 9490 7622Email: [email protected] DETAILSDate of ReferralReferringHospitalReferrers NameWardPositionContact Number and Fax NumberPATIENT DETAILSFamily NameGiven Name/sDate of BirthGender Date Created: May 2020Page 1 of 5AddressPrivate Health InsuranceFund & NumberReferring Service URNo.Medicare NumberPermanent AustralianResident Yes NoLanguage/s SpokenInterpreter Required Yes NoInterpreter LanguageRequiredGP NameGP Address FemalePost codePhone No.Mobile & HomePerson Responsible/ Guardian NameRelationship toPatientMalePhoneGP PhoneNumberGP FaxNumber Yes No Not known

Patient Family & Given Name/sINJURY & CURRENT HEALTH STATUSInjury DateCompensable Yes (TAC) Pushbike Accident OtherYes (Vic WorkCover Authority) TAC / WorkCover Claim NumberInjury CauseBrain Injury Type Motor Vehicle / Motor Bike Accident Industrial / Work Fall Stroke Ischaemic Stroke Haemorrhagic Non TraumaticBrain Dysfunction L sided Sub-Arachnoid Haemorrhage Pedestrian R sided AssaultOtherAnoxic Brain DamageOther Non–Traumatic Brain Dysfunction TraumaticOpen Injury Closed InjuryOther injuries (list)TBI ONLY: GCS Glasgow Coma ScaleTBI ONLY:Loss yCriteria(This section must becompleted if patient hasa tracheostomy)GCS on Admission Yes YesNo If Yes - Period of Lossof ConsciousnessUnknownIf Yes – Date andSurgery Description: No GCS at time of referral YesDate In:NoDate Out:Pt requires 30% inspired O2 Yes NoNo assistance with ventilation in last 72 hours Yes NoSats 95% last 24 hours Yes NoRequires 4hrs suctioning Yes NoCook tracheostomy with cannula in situ Yes NoComments:Other Tracheostomy ManagementIssues / complicationse.g. frequency of suctioning, sputum load,cuff deflation, failed or unplanneddecannulation, tube obstruction/displacement, wound breakdown, infectionor bleeding, pneumothorax/ haemothoraxIf applicable attach suction chartPage 2 of 5TBI ONLY:Post-traumatic amnesia (PTA)If out of PTA, period of PTAIf still in PTA, state last 3 days ofWestmead PTA Scale ScoreDate Created: Sep 2020Other Medical and / orSurgical Problems Yes No If Yes – Out of PTA?Unknown YesDatesDaysDateDateDateScoreScoreScore NoNo

Patient Family & Given Name/sINJURY & CURRENT HEALTH STATUS cont.Psychiatric History / CurrentPsychiatric IssuesIf current psych issues attachpsych plan and progress notesRelevant Medical HistoryDrug / Alcohol / SmokingHistoryHistory of Behavioural /Forensic IssuesHistory of Seizure Yes, specify NoCurrent MedicationsInvestigations, Results andTreatmentAllergiesIssues Requiring Return toAcute HospitalPage 3 of 5(Including Expected Timeframe forAny Planned Procedures)PREMORBID FUNCTION & SOCIAL HISTORYDate Created: Sep 2020Lives withAccommodation Alone Private Residence Supported Residential Service ( eg, Community Group Home) Residential Low Level Care (Hostel) OtherSpouse / Partner Children Boarding House Parents Friends Homeless Transitional Living UniteResidential High Level Care (Nursing Home)

Patient Family & Given Name/sPREMORBID FUNCTION & SOCIAL HISTORY contPremorbid Personal ADLEating Independent Supervised Required AssistanceShowing Independent Supervised Required AssistanceDressing Independent Supervised Required AssistanceToileting Independent Supervised Required Assistance Independent Supervised Required AssistancePremorbid Domestic ADLContinent Yes NoCommentsPremorbid Community ADL IndependentSupervised Required Assistance 1 person assistCommentsDriving YesPremorbid Mobility IndependentPremorbid Mobility AidPremorbid CognitionHighest Level of EducationObtainedPremorbid Occupation No Supervised 2 person assistSpecify Intact Mild Impairment Moderate Impairment Secondary School not completed Year 12 or equivalent TAFE Certificate Diploma Bachelor Degree Post Graduate Employed Not in labour force Student Unemployed Retired (for age) Retired (for disability) No carer & does not require No carer & requires one Carer not living in Carer living in (not co-dependant) Carer living in (Co-dependent)Nature of Premorbid Work orStudy (if applicable)Pre-Existing Carer StatusWere any services received in month prior to impairment (if living in private residence)?If yes, specify Domestic Assistance Meals Provision of goods & equipment Allied Health Care YesSocial Support No Nursing CareTransport Services Personal CareCare ManagementCURRENT FUNCTIONAL LEVEL & CARE NEEDSDate Created: Sep 2020Page 4 of 5Current Behavioural Issues1 Absent2 Present to a Slight Degree3 Present to a Moderate Degree4 Present to an Extreme DegreeShort attention span, easy distractibility, inability to concentrate 1 2 3 4Impulsive, impatient, low tolerance for pain or frustration 1 2 3 4Uncooperative, resistant to care, demanding 1 2 3 4Violent and or threatening violence toward people or property 1 2 3 4Explosive and/or unpredictable anger 1 2 3 4Pulling at tubes, restraints, etc. 1 2 3 4Wandering from treatment areas 1 2 3 4Restlessness, pacing, excessive movement 1 2 3 4Self-abusiveness, physical and/or verbal 1 2 3 4Other

Patient Family & Given Name/sCURRENT FUNCTIONAL LEVEL & CARE NEEDS ContCurrent Behaviour /Management StrategiesWeight Bearing Restrictions Full Weight BearWalking Independent Partial Weight BearSupervised Non Weight Bear1 Person assist 2 Person assist UnableYes Aids (list) Upper Limb ParesisRight Lower Limb ParesisLeftRight Continent Incontinent Indwelling catheterBowel Continent Incontinent OtherContinence NoUridomeOtherSkinPressureInjuries Yes NoList AreasInfection MRSA VRE MBL Normal diet Fluid only Thickened Nasogastric tube PEG NilPersonalADLSpatial Neglect BladderNutrition &SwallowingLeftVISABraden Score Other NectarVitamisedEating Independent Supervised Required AssistanceShowering Independent Supervised Required AssistanceDressing Independent Supervised Required AssistanceToileting Independent Supervised Required AssistanceCommunicationList deficitsList deficitsLanguageExpressionLanguage ComprehensionHearing NADVision Reading glasses Hearing aid OtherDistance glasses OtherDate Created: Sep 2020Page 5 of 5Impairments and CurrentAidsOther Progress /Outstanding Issues /Special Needs(attach additional documentsif required)Expected DischargeDestination Home IndependentHome with Supports Alternative accommodationHigh care needs Not yet knownEMR: ReferralsXX146b

The two Victorian ABI Rehabilitation Services will work closely together to determine the most suitable service to assess the patient and the most suitable bed for the patient. Both services accept public patients. Caulfield Hospital also has services for severely injured compensable TAC/ VWA