Service Requested Continence AssessmentInitial Assessment3-monthly Review6-monthly ReviewAnnual ReviewBowel AssessmentBladderBowelProducts Referrer Details Who is the Referrer? Self/FamilySupport CoordinatorHealth Care ProfessionalOther Please specify Name Email Contact Number Appointment Preference Home Visit (Location dependent)Phone ConsultOnline (e.g., Zoom) Person to Contact to Set Up Appointment Select Person ClientFamilyCarerSupport CoordinatorNext of Kin (NOK) Other (if applicable) Name Email Address Contact Number CLIENT DETAILS Client Name Date of Birth Gender MaleFemale Address-Residential Address-Postal Email Address Contact Information Mobile Home Medical Diagnosis Communication Preference SMSPhone CallEmail Direct to ClientNOKTeam LeaderSupport Coordinator Other Client Contacts – Family / NOK (If Required) Name Relationship SpouseParentNOKAdvocate / Guardian Phone Number Email Address For NDIS Participants NDIS Goals NDIS Plan details for the Service Agreement NDIS Reference Number Plan Start Date Plan End Date Funding to invoice to Preference – use Core SupportsCapacity Building Plan Management Type Plan ManagedSelf ManagedNDIA-Managed NDIA Details WE invoice under "Disability Related Fealth Supports - Nursing Supports" Preference - use: Core SupportsCapacity Building Person to Send the Service Agreement To ClientAdvocate / GuardianSpouse / Family / CarerSupport CoordinatorOther Email (If Not Already Included Above) For Plan-Managed Plan Manager Name Plan Manager Email For Self-Managed Email to send invoices to For AGED CARE PACKAGE CLIENTS Aged Care Package Details Aged Care Number (AC Number) My Aged Care Referral Code (For each service type if applicable) Funding Type Home Care Package (HCP)Commonwealth Home Support Programme (CHSP)Department of Veterans’ AffairsPrivate Package Level Level 1Level 2Level 3Level 4 Start Date of Package End Date of Package Preferred Invoice Email DOCUMENTATION Person to send the Service Agreement to ClientSpouse / Family / CarerSupport CoordinatorAdvocate / GuardianOther Email (if not already included above) Person to send the Report to ClientSpouse / Family / CarerSupport CoordinatorAdvocate / GuardianOther Email (if not already included above) CLINICAL HISTORY & ASSESSMENT INFORMATION (ESSENTIAL FOR REVIEW) Reason for Review / Presenting Issue(s) Why is this review being requested? Any specific concerns or changes? Continence History Has there been any change in bladder or bowel habits since the last assessment? Any history of UTIs, constipation, or incontinence episodes? Frequency of accidents (day/night)? Current Continence Management Plan What is currently in place? (e.g., use of products, toileting schedule, prompted voiding) Is it effective? Are there any concerns? Medications (especially those affecting bladder/bowel) Include laxatives, diuretics, anticholinergics, opioids, etc. Mobility & Transfers Can the participant independently transfer to/from the toilet? Requires assistance or equipment? Toileting Access Type of toilet facilities (e.g., commode, urinal, standard toilet)? Accessibility or safety issues? Fluid & Diet Intake Approximate fluid intake per day? Any dietary factors influencing continence (e.g., fibre intake)? Cognitive/Behavioural Factors Does the participant understand and follow continence strategies? Any cognitive issues affecting continence? Skin Integrity Any concerns with pressure areas, rashes, or breakdown due to incontinence? CONTINENCE PRODUCT USE Current Products Used Brand/type of pads, pull-ups, catheters, appliances, etc. How many per day? Issues with Current Products Leaks, rashes, discomfort, incorrect sizing? Funding for Products Currently receiving continence products through CAPS, NDIS, or private purchase? CATHETER/SPC/APPLIANCE INFORMATION (if applicable) Type of Catheter Used Change Schedule Any Complications REVIEW DETAILS & CLINICAL CONSIDERATIONS Previous Assessment Date Assessment Reports Are there any existing reports or plans from past reviews that we should reference? Hospitalisations or Recent Events Any recent hospital stays, surgeries, or infections related to continence? Desired Outcomes from This Review What are the expectations for this review? Adjustments to current plan, product changes, re-education? REVIEW DETAILS & CLINICAL CONSIDERATIONS Other Nursing Needs Interpreter Required?
