Get continence assessment template 2023-2024

CONTINENCE-RELATED ASSISTIVE TECHNOLOGY ASSESSMENT TEMPLATE For AT supports of NDIS AT Complexity Level 2 3 and 4. PART 1 - Details NDIS PARTICIPANT DETAILS Name DOB Address Contact telephone number Alternative Contact/Guardian NDIS Number Participant s NDIS Contact name phone number AT ASSESSOR You must be able to provide evidence of competence in assessing this type of AT on request from NDIS Auditor Position Business Name Email address Date s of initial assessment Date of Report State Equipment Supply Scheme Prescriber Number if relevant PART 2 - Participant s Goals and Continence assessment request PART 3 - Evaluation / assessment A. Notes for Assistive Technology AT Assessors of Continence AT Supports Check the NDIS Assistive Technology page for the current version of this form. This is the NDIS Continence-related AT Assessment Template and there are specific templates for the following types of AT Nutrition Support Prosthetics and Orthotics General AT The information provided in this form will be used by NDIS to understand how the specified AT will support the achievement of the participant s goal and to assess whether it is reasonable and necessary with regard to the criteria in Section 34 of the National Disability Insurance Scheme Act 2013 see informative extract on the following page. Current Continence Supports in use factors which may impact current Identify continence equipment / environmental/health factors which may impact current assessment and goal achievement. If it is the view of the NDIS participant or AT assessor that another relevant item of AT involved in goal achievement needs to be reassessed before this AT assessment progresses joint contact should be made with Participant s LAC or Support Plan Coordinator at this point. Section 1 - Consideration of health issues and related aspects o Have the participant and AT Continence Assessor considered health issues and other related aspects that may influence the need for continence support Yes No o Has the AT Continence Assessor recommended that the participant seek health or medical assessment and advice from any of the following health or allied health professionals Tick relevant health professional s recommended o Allied Health Professionals Medical Physiotherapist General Practitioner Dietician Occupational Therapist Medical Specialist o Is subsequent medical specialist advice recommended If yes please give details Has the participant agreed to seek this advice How might the outcome of this advice change the recommended NDIS AT continence supports to achieve participant s goals Please give details Section 2 - Current supports relevant to goal Type of Continence Product Usage Participant s report of suitability Does it need reassessment Are there additional continence product/training needs identified by participant/AT Assessor Are there other AT devices or adaptations of relevance e.g. toileting equipment toilet modifications PART 4 - Exploration of Additional Continence Interventions/ Options Provide a statement of all continence options considered - including extra continence care and education requirements - in the table below. A. Evaluation of options Thorough list of alternatives including use of other supports and approaches. Background B. Functional Assessment findings What are the applicant s measurements Height Type of loss UI FI cm Weight kg UI FI C. Current Continence Supports in use factors which may impact current Identify continence equipment / environmental/health factors which may impact current assessment and goal achievement. If it is the view of the NDIS participant or AT assessor that another relevant item of AT involved in goal achievement needs to be reassessed before this AT assessment progresses joint contact should be made with Participant s LAC or Support Plan Coordinator at this point. Section 1 - Consideration of health issues and related aspects o Have the participant and AT Continence Assessor considered health issues and other related aspects that may influence the need for continence support Yes No o Has the AT Continence Assessor recommended that the participant seek health or medical assessment and advice from any of the following health or allied health professionals Tick relevant health professional s recommended o Allied Health Professionals Medical Physiotherapist General Practitioner Dietician Occupational Therapist Medical Specialist o Is subsequent medical specialist advice recommended If yes please give details Has the participant agreed to seek this advice How might the outcome of this advice change the recommended NDIS AT continence supports to achieve participant s goals Please give details Section 2 - Current supports relevant to goal Type of Continence Product Usage Participant s report of suitability Does it need reassessment Are there additional continence product/training needs identified by participant/AT Assessor Are there other AT devices or adaptations of relevance e.g. toileting equipment toilet modifications PART 4 - Exploration of Additional Continence Interventions/ Options Provide a statement of all continence options considered - including extra continence care and education requirements - in the table below. If it is the view of the NDIS participant or AT assessor that another relevant item of AT involved in goal achievement needs to be reassessed before this AT assessment progresses joint contact should be made with Participant s LAC or Support Plan Coordinator at this point. Section 1 - Consideration of health issues and related aspects o Have the participant and AT Continence Assessor considered health issues and other related aspects that may influence the need for continence support Yes No o Has the AT Continence Assessor recommended that the participant seek health or medical assessment and advice from any of the following health or allied health professionals Tick relevant health professional s recommended o Allied Health Professionals Medical Physiotherapist General Practitioner Dietician Occupational Therapist Medical Specialist o Is subsequent medical specialist advice recommended If yes please give details Has the participant agreed to seek this advice How might the outcome of this advice change the recommended NDIS AT continence supports to achieve participant s goals Please give details Section 2 - Current supports relevant to goal Type of Continence Product Usage Participant s report of suitability Does it need reassessment Are there additional continence product/training needs identified by participant/AT Assessor Are there other AT devices or adaptations of relevance e.g. toileting equipment toilet modifications PART 4 - Exploration of Additional Continence Interventions/ Options Provide a statement of all continence options considered - including extra continence care and education requirements - in the table below. A. Evaluation of options Thorough list of alternatives including use of other supports and approaches. Where trials have been conducted please give details of where the trials took place and for how long.