Application for admission to the Subsequent Care Department

I. Client details

Surname

Native surname

Name

Birth number

ID card number

Health insurance company

Status

Permanent residence

Postalcode

Nationality

General practitioner

Name

Address

Phone

E-mail

Fax

To be completed by the proposing physician

Current epicrishes including essential medical findings

Movement:

independently with assistance

with 1 supporting aid

with 2 supporting aids

with low walker

with high walker

mechanical wheelchair

handles moved independently

assistance with wheelchair transfers

recumbent

Emptying - urine continent incontinent PMK

Defecation - Stool continent incontinent

Orientation, cooperation fully cooperative, place and time oriented limited cooperation, impaired orientation minimal or no cooperation, disorientation sensory impairment (blindness, deafness) psychiatric disorders (neurosis, psychosis, dementia) restlessness conflicting

Cooperation in rehabilitation active, fully cooperative partially active completely passive totally passive

Decubitus ulcers

superficial (localisation, extent)

deep (localisation, extent)

MRSA yes no

Legal capacity restriction proceedings initiated yes no

Where, when

Proceedings closed yes no

When, result

That is, the client has no signs of infectious disease, psychiatric illness with significant restlessness dangerous to self and others, or acute somatic illness contraindicating admission to ONP.

Name of the administering physician

Date

Full name of the facility

Address

E-mail

Phone

Fax

II. Information about the nearest relative /contact person/ - to be filled in by the social worker, client or relative

Name and surname

Address

Phone

E-mail

Name and surname

Address

Phone

E-mail

III. Social investigation

Since (date)

Klient je nyní umístěn (uveďte aktuální místo pobytu v době podání této žádosti. V případě zdravotnického či jiného zařízení uveďte jeho název a kontakt)

Client lives with family alone in a retirement home social care institution, nursing home

An application has been submitted to some social facilities yes no

Takeover after the end of the stay family retirement home nursing home nursing service provided

Contribution to care yes no

IV.Declaration of the applicant (relatives, caregiver):

Jsem si vědom(a), že žádám o přijetí do zdravotnického zařízení, odkud budu po ukončení léčby (buď zhojením nebo stabilizací procesu, kdy již nebude možné dalším pobytem docílit podstatné zlepšení zdravotního stavu) propuštěn.

Date

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