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