Referral form
Long-Term Care Medical Assessment
The long-term care medical is the clinician's part of a placement package. In Ontario it sits with Home and Community Care Support Services and the home's admission file. Other provinces have parallel medicals. It is not a home-care referral and not a hospital discharge summary pasted into a PDF.
What placement needs medically
Homes need to know whether they can care for this person: diagnoses, medications, cognition, mobility, continence, feeding, behaviours, infections, and whether the person is medically stable enough to leave acute care. Inflating behaviours to jump a wait-list, or hiding them so a home accepts, both fail later.
Use the current provincial medical. Ontario's package has changed names with each reorganization. If the care coordinator sent a form, use that one. A 2014 'level of care' booklet from a filing cabinet is not current.
Stable enough for LTC is a clinical call
Active investigation of a new mass, untreated delirium, or IV meds the home cannot give means not ready. Write what would make them ready. Do not certify 'medically stable' because the hospital needs the bed.
Who completes it
The most responsible physician or NP. In hospital, that is often the attending, not the FP who has not seen the person in two years. If you are the FP, say the last time you examined them and what you took from the hospital notes.
How to complete the medical
- Problem list that actually drives care: dementia type if known, heart failure class, wounds, insulin, dialysis, oxygen.
- Medications, including PRNs that are used, not only the ones on the eMAR theoretically.
- Cognition: last MMSE/MoCA if you have one, day-to-day examples, wandering, exit-seeking.
- Behaviours: what happens, how often, what works. 'Aggressive' is not a description. 'Strikes during personal care 3×/week, settles with two-person slow approach' is.
- Mobility and transfers, continence, feeding and diet texture, devices.
- Code status and SDM, if the form asks — as already documented, not a new conversation you did not have.
- Infectious status (C. diff, TB, resistant organisms) as known.
- Whether you will remain MRP after admission, if asked.
Worked example (fictional)
Hospital — mixed dementia, waiting LTC
Fictional 84-year-old. Do not copy onto a real placement medical.
MRP: hospitalist. FP last saw 2024. SDM: daughter (POA personal care). Diagnoses: mixed Alzheimer/vascular dementia (2019), HFpEF, BPH, stage 3 CKD, healed stage 2 sacrum. Function: two-person assist stand-pivot, wheelchair for distance. Incontinent urine, occasional stool. Eats minced, independent with setup, 70% of meals. No tube. Cognition: MoCA 11 (June 2026). Does not know the ward. Exit-seeking evenings ~4 nights/week; responds to a sitter and a closed unit. No weapon history. Behaviours: resistive to bathing 2×/week, one grab of a PSW's wrist last month, no injury. No sexual disinhibition. Meds: donepezil 10, furosemide 20, tamsulosin, vitamin D. PRN melatonin used most nights. No standing antipsychotic. Infectious: MRSA screen negative this admission. Medically stable for LTC: yes, no IV, no oxygen, delirium cleared 10 days ago. Not a home-care-only package — 24-hour care required.
Why homes bounce the package
- Behaviours left blank when the nursing notes are full of them.
- Unstable medical issues still in play.
- Medication list a month out of date.
- No SDM named.
- Using a home-care referral as the LTC medical.
Draft the LTC medical from the visit
In Scribeberry, open Forms, search for long-term care medical, or upload the current provincial PDF. Generate from the encounter and your notes, then edit every field before you sign. Scribeberry does not pre-map this form. You still review and sign.
Frequently asked questions
Can I complete this without seeing the patient?
You need enough current information to certify stability and function. A hospitalist who examined them today can. An FP working only from 2022 clinic notes should not sign as if they had.
Do I have to stay on as MRP after admission?
Only if you agree. The form may ask. Homes have their own medical staff models. Do not tick yes as a courtesy you cannot keep.
Is this the same as a capacity assessment?
No. Placement needs an SDM when the person cannot decide. A formal capacity assessment is a separate document if the province requires one.
Does Scribeberry file the LTC application?
No. Scribeberry helps you complete the medical PDF. The placement office and the family file the package. You keep a copy in the chart.
Forms
