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Integrated Care Service

Residential Service Placement Application (For Reference)

1. Please use this as a reference copy of the different tabs and fields in Integrated Referral Management System (IRMS).

2. All Residential Service Placements have to be submitted online via IRMS, no hardcopy referrals are allowed.

3. Some components of this Form can be detached and submitted as hardcopies for the IRMS Referral

i. Medical Report (Page 6, 7 and 8)

ii. Dementia/Psychiartic Report (Page 9) – where needed

iii. Nursing Procedures (Page 12)

iv. Occupational Therapy Report (Page 17) – where needed

v. Physiotherapy Report (Page 18 and 19) – where needed

vi. Speech Therapy Report (Page 20) – where needed

4. This Form applies to the Application for Residential Services

Sheltered Home with MSF subsidy (AWWA, GEHA, PERTAPIS, SASCO Evergreen Place)

Sheltered Home without MSF subsidy

Senior Group Home (MSF programme)

Nursing Home with MOH Subsidy

5. Please contact Singapore Silver Line at 1800-650-6060 or [email protected] if you have any enquiries regarding residential service placements.

Helpline: 66036800

Application to Residential Services (Please tick)

Sheltered Home with MSF subsidy (AWWA, GEHA, PERTAPIS, SASCO Evergreen Place)

Sheltered Home without MSF subsidy

Senior Group Home (MSF programme)

Nursing Home with MOH Subsidy

(BOLD fields are mandatory)Referral Source

Source of Referral : ______________________

Date of Referral submission: ____________________

Date of Referral creation: _______________________

Tel: ___________________________________Fax: _________________________________________

Patient Biodata

Patient Information

Name: ______________________________________

_______________________________________

NRIC/Fin Number/ Passport /:____________________

Date of Birth (dd/mm/yyyy): _________ Age: ___

Gender: Male Female

Citizenship:

Singapore Pink IC

Singapore PR / Blue IC

Not available

Others (_____________)

Language Spoken:

English Mandarin Malay Tamil

None Others (____________)

Race:

Chinese Indian Malay

Eurasian Others ( _______________)

Religion:

Buddhism Christianity Islam

Hinduism Others (______________)

Marital Status:

Single Married Widowed

Separated Divorced

Telephone 1 : ________________________

Telephone 2 : ________________________

Telephone 3 : ________________________

Dialect(s) Used:

Cantonese Hainanese Hokkien

Teochew Others (______________)

NRIC Address

Block ______________________________

Level ______________ Unit __________

Street _____________________________________

Postal Code ____________________________________

Completed By:

Name

:

Designation:

Handphone/Tel:

Telephone

:

Email:

Date:

Name of Applicant:

NRIC:

Other Information

Living Arrangement

Alone

With Spouse Only

With Spouse and Children

With Children(s)

With Another Relative(s)

With Non-related Person(s)

In Institution

Others (______________________)

Lift Landing

Yes

No

Not applicable

Type of Current Accommodation:

Status: Rent Own Lodge

HDB (1 / 2 / 3 / 4 / 5 / Jumbo / Mansionette room)

Institution (____________________)

Private Apartment / House / HUDC / Executive Condo

Others (______________________)

Discharge Destination

NA NRIC Address Non NRIC Address ________________________________________________________

Contact Person and/or Caregiver Information

The applicant is a destitute or person with no relatives or contact person

The applicant has a *person-in-charge / contact person (please complete the following section)

Name: _________________________________________

Address ____ ___________________________________

Address ________________________________________

Relationship: ____________________________________

Remarks: _______________________________________

Decision Maker Carer

Home Phone: ____________________

Office Phone : ___________________

Hand phone : _____________________

Others : __________________________

Email : ___________________________

Name: _________________________________________

Address ________________________________________

Relationship: ____________________________________

Remarks: _______________________________________

Decision Maker Carer

Home Phone: ____________________

Office Phone : ___________________

Hand phone : _____________________

Email : ___________________________

Has Care Giver been identified?

NA Yes No

Existing Maid Applying Maid Family Others ________________

Completed By:

Name

:

Designation:

Handphone/Tel:

Telephone

:

Email:

Date:

Name of Applicant:

NRIC:

Service Application

Does the applicant/ family have any preferences in terms of the following (but not limited by it)?

Diet : Vegetarian Non-vegetarian Halal No Preference Others (Please specify) _________________

Location : Yes No

Central East North-East North West

Preferred Service Provider : ___________________________ (Nursing Home only)

Religion: Yes No

Buddhist Roman Catholic Islam Christianity Taoism Others (Please specify) ______________

Current Location of Applicant

Hospital

Expected Discharge Date (dd/mm/yyyy) ________________

Home

Others:_____________ (Sheltered Home/Senior Group Home only)

Institution

Expected Discharge Date (dd/mm/yyyy) ________________

Discharge Planning

Is applicant known to other community services Yes No

Is applicant Known to Medical Social Worker / Case Manager / ACTION Team / Others

Name : _____________________________

Designation : ________________________

Telephone : ________________________

Email : ____________________________

Name : _____________________________

Designation: _________________________

Telephone : ________________________

Email : ____________________________

Rehab Referral

Has applicant been referred for therapy? (Please attached attending Therapist’s Report )

Physiotherapy Occupational Therapy Speech Therapy Not Applicable

Applicant‘s TCU

Applicant requires follow up at OPD / Specialist Clinic? No Yes

Completed By:

Name

:

Designation:

Handphone/Tel:

Telephone

:

Email:

Date:

Name of Applicant:

NRIC:

Financial Information (To be completed by Medical Social Worker )

* Amount of co-payment that the Applicant can afford to pay at the point of application $ ________________

* Additional co-payment to be top-up after payouts from insurance (s) had been claimed

or other sources of income had been received (eg. rental income etc) $ _________________

NOTE: Applicant can only be EITHER a Public Assistance/Special Grant or Medical Fee Exemption Card

(MFEC) Holder

Not Applicable

The applicant is on Public Assistance

* PA Ref No: ________________________

* SSO (Pls specify): _____________________________________________

The Applicant is on Medical Fee Exemption Card (MFEC No__________________________ )

The applicant has insurance coverage/financial scheme (eg. Eldershield, IDAPE, PGDAS, Silver Support Scheme etc.)

ElderShield (If applicant is receiving the payouts, how much and since when)

IDAPE (If applicant is receiving the payouts, how much and since when)

Pioneer Generation Disability Assistance Scheme (PGDAS)

Dependent Protection Scheme (DPS) [For applicant without NOK]

Silver Support Scheme (SSS) (If applicant is receiving the payouts, how much and since when)

Others (please provide details)

Has MOH/MSF Means Test been initiated? Yes No

For Residential ( NMTS )

NMTS Subsidy level:

0% / 10% / 20% / 30% / 40% / 50% / 60% / 75%

Submission Date:

Valid until:

Completed By:

Name

:

Designation:

Handphone/Tel:

Telephone

:

Email:

Date:

Paste ID Label here

AIC/ Residential Services /Ref_0001_V2

2

All Residential Service Placements to be submitted online via IRMS

AIC/ Residential Services /Ref_0001_V3

Name of Applicant:

NRIC:

Medical Report – Page 1(To be completed by Referring Doctor)

Primary Diagnosis Description

Secondary Diagnosis Description

Does the applicant have any of the following?

NA

Malignant Disease (Please specifies and state prognosis ________________________________________)

Dementia* (Please complete Dementia/Psychiatric report)

Psychiatric Problems* (Please complete Dementia/Psychiatric report)

Depression* (Please complete Dementia/Psychiatric report)

MDRO Clinical Records/History of Clostridium difficile (Please note that NHs do not admit applicants with infective MDROs)

* Does the applicant have any MDROs? Yes No

* If yes to the above question, is the applicant colonized with any MDROs? Yes No

· If no, please note that Medical team should complete treatment before raising the referral

· If yes, please indicate type/s of MDRO/s*

MRSA MRAB VRE CP-CRE Other MDROs ______________________________

* Does the applicant have C. Difficile diarrhea? Yes No (If yes, please note that applicant will only be transferred to NH if there is no more diarrhea)

Name of Applicant:

NRIC:

Medical Report – Page 2

(To be completed by Referring Doctor)

Brief Clinical History on Treatment of Current / Past Medical and Surgical Problem(s)

A) Present main complaints / Past medical and any surgical procedures and history (if any) / Summary of Management Plan {(to date) include special treatment e.g. chemotherapy / DXT}

History

Procedure Description

Date / Time

B) Investigations, significant laboratory results/ radiology (e.g MRI, CT Scan)/ Scan findings:

Lab Results

Latest Chest X-Ray Results

Date Taken: _______________________

· No pulmonary lesions suggestive of active infection

· Abnormal

C) Drug Allergy History

No Yes, specify:

Drug Allergy Description

Date ( dd/mm/yyyy ______________ )

Reaction :

1.

6.

2.

7.

3.

8.

4.

9.

5.

10.

Name of Applicant:

NRIC:

Medical Report – Page 3

(to be completed by Referring Doctor)

D) Current Medication : Route / Name of Drug / Dose / Frequency

1)Medication Name :

Dosage Regimen :

Route :

2)Medication Name :

Dosage Regimen :

Route :

3)Medication Name :

Dosage Regimen :

Route :

4)Medication Name :

Dosage Regimen :

Route :

5)Medication Name :

Dosage Regimen :

Route :

6)Medication Name :

Dosage Regimen :

Route :

7)Medication Name

Dosage Regimen :

Route :

8)Medication Name

Dosage Regimen :

Route :

9)Medication Name

Dosage Regimen :

Route :

10)Medication Name

Dosage Regimen :

Route :

11)Medication Name

Dosage Regimen :

Route :

12)Medication Name

Dosage Regimen :

Route :

E) Applicant requires rehabilitation?

Yes Trial Rehab Only No NA

* If Yes, is applicant fit to undergo rehab : Yes No

F) Weight Bearing Status

Full Partial Non-Weight- Bearing NA

Completed By:

Referring Dr

:

Referring DR MCR No. :

Hospital/Dept/Clinic

:

Contact No./Email:

Name of Applicant:

NRIC:

Dementia / Psychiatric Care(to be completed by the doctor if applicant is diagnosed as suffering from Dementia / Psychiatric Problems )

Type of Dementia / Psychiatric Disorder :

Multi- Infarct / Vascular Alzheimer ‘s Disease Others

Dementia / Psychiatric Disorder Follow Up : No Yes ( Please provide details below )

Diagnosing doctor

Name : _________________________________

Neurologist Psycho-geriatrician Geriatrician Psychiatrist Dr with postgrads GRM/Psy/FM

Designation : _______________________________

Institution : _______________________________

Cognitive & Behavioral Symptoms ( Please tick if present & provide details ) :

Paranoid & Delusional Ideation ________________________________________________________________

Hallucinations _________________________________________________________________

Day / Night Disturbance _________________________________________________________________

Sundown Syndrome _________________________________________________________________

Anxieties & Phobia _________________________________________________________________

Does not exhibit this behaviour _________________________________________________________________

Activity Disturbance

Wandering Purposeless Activity Inappropriate Activity

Aggressiveness

Verbal Outburst Physical threats &/or Violence Agitation

Affective Disturbance

Tearfulness Depressed Mood / Other

Additional Remarks / Details

Completed By:

Referring Dr

:

Referring DR MCR No. :

Hospital/Dept/Clinic

:

Contact No./Email:

Name of Applicant:

NRIC:

Functional Status – Page 1(Please also attach if therapy report is present)

Previous Functional Status ( Prior to onset of Present illness )

Feeding

Independent

Needs

assistance

Dependent

Toileting

Independent

Needs assistance

Bed Pan Commode Urinal Na

Dependent

Diapers Urinary Catheter

Mobility

Na

Ambulant

Level of assistance

NA Minimal Moderate Maximum Total

Dependence

Aids

Na Quad Stick Walking Walking Others

Frame Stick ___________

Environmental Access

Homebound Limited Community Ambulant

Full Community Ambulant

Bedbound

Wheelchair Bound

Level of assistance

NA Minimal Moderate Maximum Total

Dependence

Environmental Access

Homebound Limited Community Ambulant

Full Community Ambulant

Name of Applicant:

NRIC:

Functional Status – Page 2( Please also attach if therapy report is present)

Current Functional Status Date of Onset of current illness (dd/mm/yyyy) - __________________

Mental Status

Oriented and Rational

Confused

Alert but uncommunicative

Others(___________)

Visual Impairment

No

Yes

(Please specify _________________)

Hearing Impairment

No

Yes

Please specify

(_________________)

Transfer

Independent

Minimal

Moderate

Maximum

Total Dependence

Mobility

Ambulant

Level of assistance

Na Independent Minimum Maximum

Aids Needed

Na Quad Stick Walking Frame Walking Stick

Others

Bedbound

Wheelchair Bound

Na Independent Minimum Maximum

Activity Tolerance

Poor

Fair

Good

Feeding

Independent

Needs Assistance

Dependent

Toileting

Independent

Needs Assistance

Na Bed pan Commode Urinal

Dependent

Diapers Urinary Catheter

Bowel Management

Diapers

Colostomy

Ileostomy

Others(______________)

Respiratory Care

NA

Suction ( Suction Frequency - __________________________)

O2 Therapy ( Continuous/PRN @_________________________L/min)

Tracheostomy

BIPAP

Others( ___________________________________________________)

Dialysis

No Yes : Type of Dialysis : PD(CAPD/APD)* HD (AVF/Perm Cath)*

* To delete accordingly

Completed By:

Name

:

Designation:

Handphone/Tel:

Telephone

:

Email:

Date:

Name of Applicant:

NRIC:

Nursing Procedure

[to be completed by nurse, case manager or doctor]

NA

Feeding Tube

Due for changing on dd/mm/yyyy ______________

Type :

Flexiflo Ryles Tube Others(______________)

Size :

Urinary Catheter

Due for changing on dd/mm/yyyy ______________

Type :

Continuous Intermittent Catheterisation ( CIC )

Frequency_______________________________

Indwelling Catheter ( IDC )

Suprapubic Catheter

Size :

Stoma Care

Tracheostomy

PEG

Colostomy

Ileostomy

Wound Care

Type :

Foot Ulcer

Incision Ulcer

Pressure Sore [ ] Stage ______________

Others( Please specify ________)

Site : _____

Dressing Type :_____

Date of Last Change ( dd/mm/yyyy ) : ______

Frequency of Change____________________

Size :

Injection

Type :

IM SC IV Antibiotics

Name of Drug :

Last injection date ( dd/mm/yyyy ) ______________

Frequency :

Dosage :

Other Procedure

Completed By:

Name

:

Designation:

Handphone/Tel:

Telephone

:

Email:

Date:

Name of Applicant:

NRIC:

Resident Assessment Form – Page 1


RAF

Score (please circle) with Description for Each Score

Q1 – Mobility

(and Transfer)

- Refers to a resident’s ability to move from one point to another and includes transfer

- Excludes supervision of a wandering or mentally disturbed resident (included in Behavioural Problems Q9)

A

B

C

D

0 points

3 points

10 points

16 points

Independent

Requires some assistance (physical/assistive device)

Requires frequent assistance/turning in bed

Requires total physical assistance

- Includes walking aid/wheelchair independent residents- Requires no assistance in mobilizing and transfer (whether walking or using a walking aid/wheelchair)

- Needs some supervision, prompting, assistance or instructions to move around and/or transfer- Needs some supervision and physical guidance by staff in walking / use of assistive devices e.g walking frame, quad stick

- Requires frequent supervision, prompting or physical assistance by staff in walking / use of assistive devices e.g walking frame, quad stick

- Requires pushing of wheelchair and/or transfer/turning in bed

- Needs total assistance in positioning, transfer and turning of residents who are chair bound or bed-ridden

Remarks:

Q2 – Feeding

- Excludes preparation of food in kitchen and dishing out and serving of food

- Excludes pushing and/or positioning of wheelchair at the dining table (included in Mobility Q1)- Excludes insertion and maintenance of nasogastric tubes (included in Treatment Q5 under “special procedures”)

A

B

C

D

0 points

3 points

10 points

10 points

Independent

Requires some assistance

Requires total assistance

Tube feeding

- Able to eat without prompting, supervision or assistance - May need reminders for meal times

- Requires some supervision/assistance with feeding. For e.g. constant prompting, positioning of residents for meal times, further cutting up of food, cleaning up after meal times due to poor and messy eating

- Requires general or group supervision/assistance due to dysphagia (difficulty swallowing) or risk of choking

- Requires total supervision/assistance with feeding (due to dysphagia (difficulty swallowing), risk of choking, and/or poor or messy eating)

- Requires one-to-one supervision/assistance for feeding

- Includes preparation of feeds and any assistance of tube feeding by staff

Remarks:

Q3 – Toileting

- Excludes assisting residents when getting on a wheelchair and pushing to toilet (included in Mobility Q1) - Excludes care and/or emptying/draining of colostomies or catheters (included in Treatment Q5 under “special procedures”)

A

B

C

D

0 points

3 points

8 points

16 points

Independent

Requires some physical assistance

Requires commode/bedpan/urinal

Incontinent and totally dependent

- Able to conduct all toileting activities without assistance

- Needs minimal assistance/supervision with undressing and dressing, clothing adjustments, positioning over toilet bowl/commode/bedpan/urinal, or change of clothes/diapers (including pull-up diapers)/bedding

- Needs supervision/assistance throughout toileting- Needs moderate supervision/assistance to position over toilet bowl/commode/bedpan/urinal, or for diaper change

- Needs cleaning after episodes of incontinence of urine or faeces- Needs total and frequent assistance in the use of commode/bedpan/urinal/ ordiaper change

Remarks:

Name of Applicant:

NRIC:



Q4 - Personal Grooming and Hygiene

- Activities include:Bathing: including soaping, washing, dryingDressing: selection of appropriate clothing, putting on slippers, maintaining neat attireUsing devices: fitting of artificial limbs, calipers, supporting stockings, slings and splints; cleaning and fitting of hearing aids; spectacle careOral care: brushing teeth, cleaning and fitting of denturesGrooming: combing of hair, trimming of fingernails and toenails, shavingPersonal hygiene: handling sanitary napkins- Excludes changes of clothing and cleaning after episodes of incontinence (included in Toileting Q3)- Excludes changes of clothing after episodes of colostomy or catheter leakage (included in Treatment Q5 under “special procedures”)

A

B

C

D

0 points

2 points

4 points

6 points

Requires no assistance

Requires assistance for some activities/supervision

Requires assistance for all activities

Bed/trolley bathing

- Needs constant and repeated prompting, reminding or assistance throughout activities

- Total care of all activities of daily living (includes residents who may be bathed on commode, requiring total assistance for all activities)

Remarks:

Q5 - Treatment

(daily medication)

A

B

C

D

___ points

___ points

___ points

___ points

- Oral or topical medication: 1 point

- Oral or topical medication: 1 point- Injection(2): 2 points

- Oral or topical medication: 1 point- Injection(2): 2 points- Physiotherapy or occupational therapy: 4 points

- Oral or topical medication: 1 point- Injection(2): 2 points- Physiotherapy or occupational therapy: 4 points- Special procedures(1) (1 point per 5 minutes needed to perform procedure)

(1) Special procedures include (NOT limited to): catheter care/draining of bag, colostomy care/emptying of bag, blood glucose monitoring, urinalysis, wound dressing, oxygen administration, nebulizer, tracheostomy care, feeding tube care, peritoneal dialysis

(2) Excludes injections which are PRN or administered at an external facility

- Excludes setting up trays or collecting equipment for use in procedures

Remarks:

Q6 - Social and

Emotional Needs

Includes: - Encouragement to participate in recreational and social activities- Support to families of residents who may be anxious and upset, including building relationships with them, encouraging them to visit and making them feel welcome - Intervention to help residents adjust to the routines of the nursing home - Counselling and interaction of residents to cope with emotional distress

A

B

C

D

0 points

1 points

2 points

3 points

Nil

Occasionally (1-3 times a week)

Often (4-6 times a week)

Always (daily)

Remarks:

Q7 - Confusion (loses things, loses way, disorientated)

Includes:- Dealing with confusion, disorientation and poor memory- Determining how well a resident is orientated in time, place and person- Determining resident's ability to recall remote, recent, past, immediate events- Managing episodes when resident loses his possessions, loses his way, etc- Excludes routine activity programmes or prompting to continue an activity- Excludes any increased assistance and attention required during initial settling-in period (included in Social and Emotional Needs Q6)

A

B

C

D

0 points

3 points

8 points

10 points

Nil



Always (daily)

Remarks:

Name of Applicant:

NRIC:



Q8 - Psychiatric Problems

- Scoring is based on how psychiatric symptoms* interfere with existing ability to perform activities of daily living (ADLs) based on the most recent period observed*Psychiatric symptoms include: hallucinations, delusions, lack of interest/engagement in goal-directed behaviour, prolonged low mood, pessimistic thoughts, apprehension, uneasiness

- Conditions e.g. anxiety, depression. A confirmed psychiatric diagnosis is not necessary, however there must be documentation by a healthcare professional that the resident exhibits psychiatric symptoms Includes:- Early identification of symptoms of relapses for management- Counselling of anxious and depressed residents - Dealing with situations that arise as a result of the disruptive behavior of resident due to hallucinations / delusions - Excludes adjustment problems

A

B

C

D

0 points

2 points

4 points

6 points

Nil

Mild interference in life

Moderate interference in life

Severe interference in life

Psychiatric symptoms* interfere with existing ability to perform ADLs and/or social/recreational activities around 25% of the time



Remarks:

Q9 - Behavioural

Problems

- Refers to the frequency and severity of behaviour(s) displayed by the resident based on the most recent period observed

- Includes (NOT limited to): physical aggression, verbal disruption, agitation, restlessness, non-compliance to instructions, manipulation, self-destructiveness, sexual disinhibition (repeated stripping of clothes and/or diapers, molestation), wandering, absconding, food-grabbing, hoarding, suicidal ideation and/or attempts, repetitive behaviour (e.g excessive water drinking and washing of hands) and sensory seeking behaviour (e.g playing with water and/or faeces, self-scratching)- Excludes assistance and attention given to residents during their initial settling-in period (included in Social and Emotional Needs Q6)

A

B

C

D

0 points

3 points

10 points

16 points

Nil



Always (daily)

Frequency may not be as stated above, but the behaviour is of low severity and manageable

Frequency may not be as stated above, but the behaviour is of moderate severity and manageable

Frequency may be often or always, but the behaviour is severe and difficult to manage.

Remarks:

Total Points:Category (please circle): I II III IV

Category I: ≤ 6 points, Category II: 7-24 points, Category III: 25-48 points, Category IV: >48 points

Completed By:

Name

:

Designation:

Handphone/Tel:

Telephone

:

Email:

Date:

Name of Applicant:

NRIC:

Social Report

Social Background ( includes family set-up ; living arrangement , primary care giver, main spokesperson and significant dynamics within the family and other community support received)

Functional Status and Care needs (includes premorbid functional status, previous care needs & care giving experiences / issues versus current status; clinical intervention to manage applicant’s care eg. Management of behavioural issues )

Social Criteria Assessment (includes assessment on caregiver’s availability, willingness & competency, suitability of community-based/home based services to support applicant’s care, resources for alternate care options.

Financial Assessment (includes means of substance, applicant’s financial resources and other sources of income, main decision maker for applicant’s care and financial issues)

Additional Assistance (includes assistance by Hospital, community services to support applicant’s care post-discharge eg. Transport funding secured for applicant’s dialysis appointments; purchase of oxygen concentrator for applicants on long term oxygen therapy etc.)

Recommendation

* If applicant is applying for higher government subsidy via subsidy deviation, please complete the “Application for Subsidy Deviation” form. (Nursing Home only)

Completed By:

Name

:

Designation:

Handphone/Tel:

Telephone

:

Email:

Date:

Name of Applicant:

NRIC:

Rehabilitation Summary – Occupational Therapy Report ( OT )

(to include all disciplines of therapy according to Doctor’s referral)

Self-Care / Wheelchair Mobility

Personal Hygiene / Grooming

Independent

Supervised

Contact / Minimal assistance

Moderate assistance

Maximum assistance

Dependent / Unable

Showering

Independent

Supervised


Moderate assistance

Maximum assistance

Dependent / Unable

Toileting

Independent

Supervised


Moderate assistance

Maximum assistance

Dependent / Unable

UB Dressing

Independent

Supervised


Moderate assistance

Maximum assistance

Dependent / Unable

LB Dressing

Independent

Supervised


Moderate assistance

Maximum assistance

Dependent / Unable

Feeding

Independent

Supervised


Moderate assistance

Maximum assistance

Dependent / Unable

Wheelchair Mobility

Independent

Supervised


Moderate assistance

Maximum assistance

Dependent / Unable

Applicant ‘s functioning in the aspects of cognition / perception , psychosocial and safety awareness

Other Remarks (please include caregiver training and recommendation for follow up)

Care giver Training done Yes No Not applicable

Functional Independence Measure

Admission Score _______

Discharge Score ________

MBI Total Scores Dependency Level

0 - 24 Total

25 - 49 Severe

50 – 74 Moderate

75 – 90 Mild

91 – 99 Good

Modified Barthel Index



Completed By:

Name

:

Designation:

Handphone/Tel:

Telephone

:

Email:

Date:

Name of Applicant:

NRIC:

Rehabilitation Summary – Physiotherapy ( PT ) Page 1


Mobility

Bed Mobility Status

Bedbound

Wheel Chair bound

Not Applicable

Bed Mobility

Independent

Supervised


Moderate assistance

Maximum assistance

Dependent / Unable

Ambulation

Independent

Supervised


Moderate assistance

Maximum assistance

Dependent / Unable

Walking Aid

Point Stick

Quad Stick

Walking Frame

Not applicable

Others

Transfer

Independent

Supervised


Moderate assistance

Maximum assistance

Dependent / Unable

Standing Balance

Static Standing

Fair ( Unsupported > = 5- 15secs )

Good ( Unsupported > 15secs )

Poor < = 5secs

Dynamic Standing

Fair ( Reach in 2 directions )

Good ( Multi – directional reach )

Poor < = reach in 1 direction

Sitting Balance

Sitting Standing

Fair ( Unsupported > = 5- 15secs )

Good ( Unsupported > 15secs )

Poor < = 5secs

Dynamic Sitting Direction

Fair ( Reach in 2 directions )

Good ( Multi – directional reach )

Poor < = reach in 1 direction

Exercise Tolerance

Fair 15 – 45mins

Good > 45mins

Poor < = 15mins

Muscle Strength

Right

Left

Arms

0 1 2 3 4 5

0 1 2 3 4 5

Legs

0 1 2 3 4 5

0 1 2 3 4 5

Name of Applicant:

NRIC:

Rehabilitation Summary – Physiotherapy ( PT ) Page 2


Special precautions and contra-indications

Cardiac

Fall

Postural Hypotension

Others

a) Care Giver training done. Yes No Not Applicable

b) Other Remarks ( please include care giver training and recommendation for follow up )

c) Functional Independence Measure



Modified Barthel Index



MBI Total Scores Dependency Level

0 - 24 Total

25 - 49 Severe

50 – 74 Moderate

75 – 90 Mild

91 – 99 Good

Completed By:

Name

:

Designation:

Handphone/Tel:

Telephone

:

Email:

Date:

Name of Applicant:

NRIC:

Rehabilitation Summary – Speech Therapy ( ST )


Feeding Status Mobility

Diet Texture ( Please specify ___________________________________)

Fluid Consistency ( Please specify ___________________________________)

NG Tube / PEG ( Please specify ___________________________________)

Other Compensatory Strategies ( Please specify ___________________________________)

Speech and Language Function

Comprehension

Intact

Mild Impairment

Moderate Impairment

Severe Impairment

Not Applicable

Verbal Expression

Intact

Mild Impairment

Moderate Impairment

Severe Impairment

Not Applicable

Speech

Intact

Mild Impairment

Moderate Impairment

Severe Impairment

Not Applicable

Voice

Intact

Mild Impairment

Moderate Impairment

Severe Impairment

Not Applicable

Other Remarks ( please include care giver training and recommendation for follow up )

Completed By:

Name

:

Designation:

Handphone/Tel:

Telephone

:

Email:

Date:

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