FAIRCAPE HEALTH REFERRAL FOR SUB-ACUTE ADMISSION & AUTHORISATION
FAIRCAPE HEALTH TOKAI Sub-Acute - Cnr Vans & Windsor Road, Tokai, 7945 - PN: 049 003 0680958
FAIRCAPE HEALTH SOMERSET WEST - George Hazeldon Drive, Heritage Park, Somerset West, 7130 - PN: 04900 1028 5684
FAIRCAPE HEALTH ONRUS - Chanteclair Drive, Onrus River, 7201 - PN: 04900 1022 1856
FAIRCAPE HEALTH CLE DU CAP - Pollsmoor Road, Kirstenhof, 7945 - PN: 04900 3047 5254
FAIRCAPE HEALTH NOORDHOEK- Cnr Silvermine Road & Paddock Drive, Noordhoek, 7985 - PN: 04900 1035 9467
FAIRCAPE HEALTH TOKAI Acute - Cnr Vans & Windsor Road - PN:1269895
1. REFERRING DOCTOR’S DETAILS
Name of Doctor
Doctor Telephone Number
Format: (000) 000-0000.
Email
example@example.com
2. PATIENT DETAILS
Please attach photo of patient sticker or complete details manually below
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File Upload Photo of Patient Script
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Full name
ID number
Email
example@example.com
Telephone no.
Format: (000) 000-0000.
Medical aid
Membership no
Hospital
Ward
Bed
Date of Admission to Acute
/
Day
/
Month
Year
Date
Expected date of transfer to Sub-acute
/
Day
/
Month
Year
Date
Payment Option
Please Select
Medical Aid
Private
Payment Option
Medical Aid
Private
3. MEDICAL INFORMATION
Rows
Diagnosis
ICD10 codes
1
2
3
4
5
6
Clinical Notes
Trauma History
Fall
MVA
ICD10 Code:
Cognitive conditions & Severity
Rows
Yes
No
Mild
Moderate
Severe
Associated Dementia
Delirium related condition
Trauma History:
Please Select
Fall
Mva
Associated Dementia
No
Yes
Severity:
Mild
Moderate
Severe
Delirium related condition
No
Yes
Severity:
Mild
Moderate
Severe
Clinical Notes
Complications In Hospital
4. SURGERY/PROCEDURES PERFORMED
Type
Date
/
Day
/
Month
Year
Date
Type
Date
/
Day
/
Month
Year
Date
Type
Date
/
Day
/
Month
Year
Date
Required Allied & Medical Services
Rows
Yes
No
Physiotherapy, occupational therapy, Dietetics, & Doctor
Medical Doctors
Physiotherapist
Occupational therapist
Dietitian
Speech therapist
Discharge Planner
Social Worker
Physiotherapy, Occupational Therapy & Dietetics, Doctors
Yes
No
Medical Doctors - Pr: 0823635 / 0907634
Dietitian - Pr: 0437174
Physiotherapist - Pr: 0959979
Speech Therapist - Pr: 0816604
Yes
No
Occupational Therapist - Pr: 1017403
Discharge Planner
6. INFECTION CONTROL
Isolation
Yes
No
Microbiology
Rows
Positive
Negative
MRSA/MSSA
CRE/CPE
SARS-COV-2 PCR
CRE / CPE
Positive
Negative
MRSA / MSSA
Positive
Negative
SARS-CoV-2 PCR
Detected
Undetected
Other/Please specify
Date
/
Day
/
Month
Year
Date
7. SUB-ACUTE CARE REQUIRED
Level of Assistance
Full assistance
Partial
Independent
Weight Bearing Status
Full weight (FWB)
Partial Weight (PWB)
Non-weight (NWB)
Oxygen /nebulisation
Yes
No
Catheter
Ostomy
PEG
Drain
Intravenous treatment
Yes
No
Details
Please confirm that if the patient is still needing IV fluids, IV antibiotics or acute level nursing care, that this has been discussed with and approved by one of the Faircape Doctors.
Yes
No
8. ANTICOAGULATION
Anticoagulation
Warfarin
Clexane
Xarelto
Other
9. DIETARY REQUIREMENTS
Soft Diet
Normal Diet
Puree Diet
Mince Moist Diet
Diabetic Diet
Kosher
Renal Diet
On Nutrition Supplements
Diagnoses for Food Allergies
Any Special Needs
Comments:
Comments
10. WOUND CARE
Special orders from the Referring Doctor/Special Instructions:
Date of Dressing Change:
/
Day
/
Month
Year
Date
Date of Removal of Suture/Staples:
/
Day
/
Month
Year
Date
Comments:
11. MEDICAL AID MOTIVATION
Upload Additional letter of motivation to submit to medical aids
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EXPECTED OUTCOMES/GOALS FROM SUB-ACUTE CARE
PROPOSED DURATION OF STAY TO ACHIEVE OUTCOMES
Medication: Acute and chronic script supplied at discharge
Yes
No
Signature of doctor
Doctor Confirmation information is correct
Yes
Date
/
Day
/
Month
Year
Date
On completion this will be emailed to casemanager@faircape.co.za
Submit
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