SALISBURY DISTRICT HOSPITAL WARD OR DEPARTMENT - CUSTOMISE THIS HEADING ABC BEFORE PRINTING THIS FORM OCCUPATIONAL THERAPY RISK ASSESSMENT - BED LEAVER
Patient Label :
Diagnosis:…………………………………………………………………………………………………..
Patient height:…………………………….(cm) Patient weight:…………………………(Kg)
Previous history of falls from bed ?……………………………………………………………………..
Is patient alone at night ?………………………………………………………………………………..
Why does patient need it ?………………………………………………………………………......
Other options considered ?………………………………………………………………………………
Home environment:
Has a home visit been completed to assess the bed? Yes / No (Circle)
If yes, date completed………………………. By (Name/ Profession) ……………………………
If the bed has not been seen, the information has been provided by:.
Name……………………………………………Relationship to patient……………………………..
Contact details (telephone number)…………………………………………………………………..
Style of bed (Tick): 1. Single 2. Double 3. Divan
4. Privately purchased profiling bed 5. Other………………..
Base of bed (Tick): 1. Sprung base 2. Slatted base 3. Other………………..
Thickness of mattress when compressed: ………..(cm)
Bed leaver style and design appropriate for the patient: …………………………………………
Supplier/ Catalogue number:……………………………………………………………………………..
Fitting of bed leaver -
Has the bed leaver been fitted on a home visit by the OT? Yes/No (Circle)
Has the purpose of bed leaver been explained to patient/carer? Yes/ No (Circle)
Has the safe use of the bed leaver been demonstrated to the patient/carer? Yes/No (Circle)
In hospital (Tick) : Date…………………………. At home (Tick) : Date………………………….
The safe and correct positioning of the bed lever has been discussed with:
………………………………………………………………………………………………...... Patient Name: Hospital Number:
Measurements:
1. Which side of the bed is the leaver to be fitted? Right Left (Circle)
2. Measurement from the top of the bed to the front of the bed leaver (x) ……………….cm
3. Should bed leaver be strapped to the bed? Yes/ No (Circle)
Top of bed
Pillow x = ……………cm
Bed Leaver
Left side Right side of bed of bed
Bottom of bed
The bed leaver will be fitted by:
OT ………………………………………………… Therapy assistant…………………………
Family…………………. …………………………. Carer………………………………………
Medequip Technician……………………………. Huntleigh Technician………………………
Occupational Therapist ………………………………………………………..
Date ……………………………………………………………………………...
Contact number (telephone number) ………………………………………… Sally Hall May 2008