My Traffic Light Hospital Passport

Name: ______________________

DOB: _______________________

NHS Number: ________________

Allergies: ____________________

Here are the contact details for the person who knows me best. Please involve this person in my care plan.

Name: _________________________

Tel No: ________________________

Relationship to me:_______________

This Hospital Passport should be completed by you and the people who know you best. By filling it in, you are consenting to your information being shared with the hospital and the staff who are caring for you. The Hospital Passport gives the hospital staff important information about you including any Reasonable Adjustments you may need to ensure that you get the best care, given in the right way for you. You can ask the hospital to take a photocopy and keep it in your file. Before you leave hospital make sure the Hospital Discharge Information Plan has been completed and remember to take your Hospital Passport home with you. Once you are home you may also want to fill in the Have Your Say questionnaire to tell the hospital about your experience. This will help them to improve their service.

Please let your local Community Learning Disability Team (CLDT) know that you are going into hospital as the Community Learning Disability Nurses will be able to offer you advice and support before, during and after your hospital stay.

Oldham CLDT- 0161 621 7272Heywood, Middleton and Rochdale CLDT- 01706 676767Bury CLDT- 0161 762 3263.North Manchester CLDT- 0161 861 2958

You can also discuss any worries or concerns you may have with the manager of the ward or department you are attending.

Any decisions made about your capacity to consent to treatment, best interests and resuscitation status must be made in consultation with you, your carers and other professionals.

Author- Ruth Bell Learning Disability Liaison Nurse

Version 2

Issue date Nov 2015/ Expiry Date Nov 2018

Please now fill in the Reasonable Adjustments form and make sure the nurse looking after you has seen it and taken a copy for your hospital file.

pg. 1

NHS NO.

pg. 6

NHS NO

Is an interpreter required? (Consider signing / accessible information)

Any religious or spiritual needs? (If so, how should these be met?)

Current medication?

(Please provide the hospital with a separate, up-to-date list of your medication)

Medical / health conditions: (e.g. epilepsy, heart problem, mental health condition, dementia)

Autism: Y/N (If yes, please provide details of care required on the reasonable adjustment form)

Risk Assessment / Guidelines: (e.g. dysphagia, behaviour management – please provide a copy of to the hospital for their notes)

Has mental capacity for this episode of care been assessed and

pg. 2

NHS NO.

Communication:How I communicate / understand e.g. Communication Dictionary:Please also tell us how you would like to receive information from the hospital (eg. Easy read, larger font, different coloured background, embossed, audio, braille etc)

Seeing/ hearing/ sensory (touch, smell etc.): Problems with sight or hearing, eye contact, hypersensitivity, dislike of touch etc.

Eating and drinking: Dysphagia (swallowing problems), special diet, type of drink, temperature, amount, type of cup, use of straw, positioning etc.

Taking medication: Crushed tablets, syrup, injections, medication in food, help taking medication?

pg. 4

NHS NO.

If you don’t know me it might be difficult to tell if I am ill.I may not be able to tell you myself. My carer will be able to give you helpful information. Please ask them, and also read the information below.

If you want to tell the hospital about what went well during your stay or if you are unhappy with any aspect of the service you received, you can contact the PALS Hospital Service (Patient Advice and Liaison Service). They will listen to your comments and help you sort out any problems quickly.

You can contact PALS by telephone on 0161 604 5897

Or by email on: pals@pat.nhs.uk

pg. 6

NHS NO

pg. 7

NHS NO

When I feel well and happy I …

When I feel ill I …

Things I like… You can talk to me about these.

Things I don’t like… I might not like to talk about these things.

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Reasonable Adjustments I Need

Reasonable adjustments I need in hospital NHS

The law says that all health services must think about people with learning disabilities. They have to ask “What extra things do we need to do, so that people with learning disabilities can have health services that are as good as they are for other people?” Once you have filled in the Hospital Passport please fill in the form below to tell us what extra things you need in hospital to make sure you get the service that is right for you.

Examples of reasonable adjustments include: needing accessible information about medical procedures or medication, needing a carer to stay with you, needing help with personal care, needing food and drink prepared in a certain way, having to be seen at a specific time as waiting may be difficult to understand and manage, medication needing to be given in a certain way etc.

NHS NO.I need a

reasonable adjustment

(Yes or No X )

Details of the reasonable adjustment needed for my hospital stay

Communication

Seeing/hearing/sensory

Eating and drinking

Taking medication

Going to the toilet

Moving around

Pain/distress

Carer comfort/support

Sleeping

Keeping safe

Personal care

Anything else not covered above? Please tell us here

Hospital Discharge/Information Plan

Before the patient is discharged there must be a clear handover of information back to the carer. Sometimes this means there needs to be a full multi-disciplinary meeting to discuss what is needed when the patient leaves hospital. Sometimes this can be done verbally. The important thing is that it is done and this form is completed.

Patient’s Name: _____________________

NHS NO.-----------------------------------------

Date of Admission: __________________

Date of Discharge: __________________

Ward/Department: ___________________

Doctor’s Name: _____________________

Consultant’s Name: __________________

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Present:

Date of discussion:Apologies:

Summary of what the person has been treated for/diagnosis:

Have the person’s needs changed at all? (e.g. PEG. Catheter, mobility, swallowing, diet etc.)

Is there any equipment needed? Who is providing it? (e.g. walking frame, raised toilet seat, nebuliser, inhaler, PEG feed, assistive technology etc.)

You may want to give a copy of this completed discharge plan to all parties involved in your care.

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Do carers/support staff need extra training to manage a changed health need? Details (e.g. who will provide training?)

List of medication changes/additions (incl. liquid feed). Do carers understand what these are for/how to administer/side effects to look out for etc.?

Any other referrals required/additional funding required: e.g. for physio, swallowing assessment, dietician, community learning disability nurse, transfer of care team, care management etc.?

Referral to: Named person responsible:

Any infections/pressure areas (MRSA, C. difficile, other infections). Who is managing these, have carers seen relevant policies/ need training/ resources?

How is the person getting home from hospital? (ambulance, own transport)

Any follow-up appointments/ out patients/ district nurse referral?

Please outline any action plan agreed/ any other issues: