Post Concussion Mild Traumatic Brain Injury
Adult

Occupational Therapy Rehabilitation Clinic

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Emergency Referrals

Useful Management Information

To provide time limited, goal focused specialist rehabilitation OT service for patients living in the community who require intervention to maximise their independence and occupational performance.
This service is delivered to:
- Clients with a mild/moderate TBI who were discharged from the Emergency Department without therapy follow-up.
- Specific Diagnosis of mild Traumatic Brain Injury ( GCS 13-15/15; Head strike +/- LOC, Period of amnesia or confusion and concern for mechanism of injury.
- Individual assessment/treatment of cognitive deficits
- Group sessions focusing on education and strategies to improve cognitive impairments
- Individual assessment/treatment of upper limb impairment
- Spasticity and botox clinic and follow-up sessions post upper limb botox.
- Individual assessment/treatment of visual/perception dysfunction.
- Saebo dynamic orthosis program
- Specialised intervention and treatment following an Acquired Brain Injury; Traumatic Brain Injury (TBI) or mild Traumatic Brain Injury / Post Concussive Syndrome (PCS) service

Minimum Referral Criteria

Does your patient meet the minimum referral criteria?

Category 1 (appointment within 30 calendar days)	Recent discharge from hospital/ED with suspected TBI or concussion who have not had a cognitive assessment undertaken. At risk of Post Concussive Syndrome – follow up mTBI Acquired brain or traumatic injuries / Neurological disorders / functional decline requiring specialty rehab services with onset (3-6mths prior) Assessment for high-risk clients due to new cognitive impairment New UL deficit impacting on occupational performance and return to usual activities. Assessment required to inform other medical interventions (e.g., procedure, surgery, medications) Specialised intervention as part of a time-limited rehabilitation program
Category 2 (appointment within 90 calendar days)	Acquired brain or traumatic injuries / Neurological disorders / functional decline requiring specialty rehab services with onset (<2 year ago), and: Follow up or review a gradual decline in functional cognition Follow-up or review UL function impacting on occupational performance Acute on chronic condition that results in apparent changes to functioning or new deficits Post-surgical repeat assessments
Category 3 (appointment within 365 calendar days)	Acquired brain or traumatic injuries / Neurological disorders / functional decline requiring specialty rehab services with onset (>2 year ago), Difficulties in upper limb function post ABI Difficulties in occupational performance relating to progression of chronic neurological condition.
If your patient does not meet the minimum referral criteria Assessment and management information may be found on a range of conditions at HealthPathways If the patient does not meet the criteria for referral but the referring practitioner believes the patient requires specialist review, a clinical override may be requested: Please explain why (e.g. warning signs or symptoms, clinical modifiers, uncertain about diagnosis, etc.) Please note that your referral may not be accepted or may be redirected to another service

Standard Referral Information

Reason for request

To establish a diagnosis
For treatment or intervention
For advice and management
For specialist to take over management
Reassurance for GP/second opinion
For a specified test/investigation the GP can't order, or the patient can't afford or access
Reassurance for the patient/family
For other reason (e.g. rapidly accelerating disease progression)
Clinical judgement indicates a referral for specialist review is necessary

Relevant clinical information about the condition

Presenting symptoms (evolution and duration)
Physical findings
Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
All conservative options that have been pursued unsuccessfully prior to referral
Body mass index (BMI)
Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
Any special care requirements where relevant (e.g tracheostomy in place, oxygen required)
Current medications and dosages
Drug allergies
Alcohol, tobacco and other drugs use

Patient's Demographic Details

Full name (including aliases)
Date and country of birth
Residential and postal address including whether patient resides at an aged care facility
Telephone contact number/s – home, mobile and alternative
Medicare number (where eligible)
Name of the parent or caregiver (if appropriate)
Name of delegate and contact details (Department of Corrective Services)
Preferred language and interpreter requirements
Identifies as Aboriginal and/or Torres Strait Islander
Any special needs, access requirements and/or disability relevant to the referral

Referring Practitioner Details

Full name
Full address
Contact details – telephone, fax, email
Provider number
Date of referral
Signature
Nominated general practitioner’s details (if known), if the nominated general practitioner is different from the referring practitioner

Other relevant information

Willingness to have surgery (where surgery is a likely intervention)
Choice to be treated as a public or private patient
Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)

Essential Referral Information

Clear diagnosis of head injury with relevant details
Any Scans CT / MRI.
Any previous medical history or current issues that may impact return to work / school / roles.
Any prior assessment/s; cognitive; range of motion or weight bearing restrictions and timeframes for these.
Any previous medical history or current medical issues that may impact on participation in rehabilitation programme.

Additional Referral Information

There is no additional referral information

Send Referrals To

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Secure Web Transfer

Send to: Gold Coast Health Service District

Internal Referrals

(E-Blueslips)

Fax

(07) 5687 4497

Post

Booking and Referral Centre
Gold Coast University Hospital
1 Hospital Boulevard
Southport QLD 4215

Enquiries

1300 744 284

Related HealthPathways

No directly related pathways found

HealthPathways home page

Service Availability

Facilities

Gold Coast University Hospital

If you would like to send a named referral, please address it to the specialist listed above, who will allocate a suitably qualified specialist to see the patient. Alternatively, you can view a full list of our specialists.

Post Concussion Mild Traumatic Brain InjuryAdult