Expected outcomes
Please include goals and expectations e.g. to be able to make microwave meals, wash and dress independently, mobility goals.
GP Surgery
Next of Kin
Additional Contact
Current Medical Problem
Including investigations, diagnosis, treatment and therapy assessments, any falls in the last 48 hours
Medical History
Please give details of past medical history relevant to this admission, any known allergies including any long-term conditions:
Any other infection control issues?
Please consider ESBL, C.diff etc.
Please describe level of support
eg. Physical, verbal etc
Are there any medications that are timebound?
e.g. parkinsons, diabetes
Current method of dispensing
eg. original boxes, blister pack, automated dispenser etc.
Known Allergies
If the service user has any known allergies inc drug allergies, please give details (including the impact on daily living)
Any Current Needs?
e.g. falls, mobility, nutrition, equipment etc
Please include previous situation.
Home Environment Description
Including access, stairs, care phone
Previous Function
e.g. washing and dressing, mobility inc transfers, diet and fluids, toileting etc
Support needed for daily functional tasks
Please include support needed with daily functional tasks
Communication
inc. if wears glasses or hearing aid, are they able to communicate?
Toileting
inc. if service user has colostomy or catheter
Skin Integrity
any pressure sores, wounds, creams or pressure relieving equipment
Nutrition
Meal prep, assistance with feeding
Mobility/Movement and Handling
Provide details of any equipment in place or awaiting delivery
Existing support networks (formal and informal)
Please include who does the shopping etc.
Please provide details of the best time (s) to contact you
Other Times
ie. Night support