DNS Continence Assessment Referral Form

Service Requested

Continence Assessment

Initial Assessment

3-monthly Review

6-monthly Review

Annual Review

Bowel Assessment

Bladder

Bowel

Products

Referrer Details

Who is the Referrer?

Self/Family

Support Coordinator

Health Care Professional

Other

Name

Email

Contact Number

Appointment Preference

Home Visit (Location dependent)

Phone Consult

Online (e.g., Zoom)

Person to Contact to Set Up Appointment

Select Person

Client

Family

Carer

Support Coordinator

Next of Kin (NOK)

Other (if applicable)

Name

Email Address

Contact Number

Client Details

Full Name

Date of Birth

Residential Address

Postal Address

Email Address

Contact Information

Mobile

Home

Primary Diagnosis

Communication Preference

SMS

Phone Call

Email

Direct Communication To

Client

NOK

Team Leader

Support Coordinator

Other Client Contacts – Family / NOK (If Required)

Full Name

Relationship

Spouse

Parent

NOK

Advocate / Guardian

Phone Number

Email Address

For NDIS Participants

NDIS Goals

NDIS Plan Details (Service Agreement)

NDIS Reference Number

Plan Management Details

Plan Start Date

Plan End Date

Email to Send Invoices To (if known)

NDIA Managed Type

Plan Managed

Self Managed

NDIA Details

WE invoice under "Disability Related Fealth Supports - Nursing Supports" Preference - use:

Core Supports

Capacity Building

Person to Send the Service Agreement To

Client

Advocate / Guardian

Spouse / Family / Carer

Support Coordinator

Other

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., products, toileting schedule, prompted voiding)

Is it effective? Are there any concerns?

Medications (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 (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

Receiving 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

Any existing reports or past review plans?

Hospitalisations or Recent Events

Recent hospital stays, surgeries, infections?

Desired Outcomes

Expectations from this review?

Other Nursing Needs

Interpreter Required?

Yes

No

DNS Continence Assessment Referral Form

CONTINENCE ASSESSMENT REFERRAL FORM

Service Requested

Referrer Details

Appointment Preference

Person to Contact to Set Up Appointment

CLIENT DETAILS

Client Details

Contact Information

Communication Preference

Direct Communication To

Other Client Contacts – Family / NOK (If Required)

For NDIS Participants

NDIS Plan Details (Service Agreement)

NDIA Managed Type

WE invoice under "Disability Related Fealth Supports - Nursing Supports" Preference - use:

Person to Send the Service Agreement To

CLINICAL HISTORY & ASSESSMENT INFORMATION (Essential for Review)

Reason for Review / Presenting Issue(s)

Continence History

Current Continence Management Plan

Medications (affecting bladder/bowel)

Mobility & Transfers

Toileting Access

Fluid & Diet Intake

Cognitive / Behavioural Factors

Skin Integrity

CONTINENCE PRODUCT USE

Current Products Used

Issues with Current Products

Funding for Products

CATHETER / SPC / APPLIANCE INFORMATION (If applicable)

REVIEW DETAILS & CLINICAL CONSIDERATIONS

Assessment Reports

Hospitalisations or Recent Events

Desired Outcomes

Other Nursing Needs