Order 1103231: Clinical Case study post op

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DarrenRobertsadmissionform.pdf

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UR NUMBER UR NUMBER

SURNAME SURNAME FIRST NAME FIRST NAME ADDRESS ADDRESS

DATE OF BIRTH DATE OF BIRTH DOCTOR DOCTOR

COMPLEX DISCHARGE SCREEN Discharge date & destination unclear  ADMISSION DETAILS

Frequent Presenter  Unable to return home  Provisional Diagnosis:

Homeless  Residential care required  Date of Admission:

Bariatric  Disability Services required  Past History (medical, surgical, mental health):

GEM on Acute  1 or more Community Services  Consider: CNS (nerves, brain), CVS, Resp, GIT, urinary, skin)

DISCHARGE CHECKLIST if no what action was taken or N/A

Valuables Checklist complete P (Check ED Checklist for Valuables)

Collection of Discharge Medications P Hospital Pharmacy P Own pharmacy 

Own Medications returned P PREDICTED DISCHARGE

Medical Certificate P Predicted date of discarge: Predicted destination:

Pre-admission or new services notified P Name: Transport Self P Family/Carer Taxi Ambulance Other

IV/subcutaneous cannula removed P PRE-ADMISSION SERVICES  not applicable

Dressing attended P eg HARP, HNSS, MOW, Home Help, PCA, Case Manager (include details & notify Case Manager Liason)

Post d/c action plan (e.g COPD, asthma) Oxygen ordered: 

Medical discharge summary complete and P

copy to patient P

Family/Carer notified of discharge P

Check Oxygen & Suction, change if required P

Completed Medication Chart

Medications arranged with Pharmacy 1. ADMISSION HISTORY

Residential in Reach notified of discharge Is this a re - admission to hospital:  28 days  3 months

Transfer letter completed (medical) How many times has patient been in anyhospital in past 12 months? Nil

Facility notified of discharge time 2. ORIENTATION TO UNIT

Welcome information given and explained P Patients rights & responsibilities booklist P

Inter-hospital transfer form completed P Telephone location P Introduction to other patients P Bathroom location

At discharge checked by Nurse: Date: P TV P Discharge time (10am) explained P Use of Nurse Call

VALUABLES No valuables with patients P 3. SOCIAL / LIFESTYLE NO YES

Aboriginal/Torres Strait Islander P Aboriginal Liaison Services 

Is patient identified as Culturally and P Interpreter needed? 

Hearing Aids P Linguistically Diverse? P

Dentures P Does patient have a case manager? P Notify of admission, Case Management

Glasses P Name and phone P Liaison Co ordinator 

Jewellery P Does patient have a support person/carer? P Notify of admission, Case Management

Watch P P Social Worker (if concerns) 

Electrical items P Does patient live alone? P Social Worker (if concerns) 

Mobile Phone P If no, who with (other than carer)? Name: P PAC 

Mobility Aids P Is patient a carer? P TCP 

Money and Credit Cards P if yes have arrangements been made? P

Medications P Does patient drink alcohol daily? P Doctor if possible issues 

Other Items Does patient smoke? P Complete Smoking assessment

Completion of Screen by Nurse & Patient / Significant Other nicotine dependence scale (MR92Q)

I am aware that any jewellery or valuables kept on me or in the ward area, are my responsibility and I understand that Latrobe Does patient use recreational drugs? P Doctor if possible issues 

Simulated Hospital are not accountable for any loss or damage. I understand that my care plan will be developed from the Current accommodation type: House P Unit  Caravan 

information I have provided above Aged care facility  Low care  High Care  SRS 

Nurse & Patient or significant other must sign. If unable to sign, state a reason why: Will current home arrangements be an issue on discharge? Social Worker 

4. ADVANCE CARE PLANNING NO

Patient Name: Date: Does the patient have an Advance Care Plan? P

Nurse Name: Date: Enduring Power of Attony (medical treatment)? P

Enduring Power of Guardianship? P

Refusal of Treatment Certificate? P Entered on IPM? 

ROBERTS Darren 25 Happy Street CAIRNS 4860 23/11/1968 John Smith

if P to any, activate Complex

Discharge Process

Patients returning to Residential Aged Care Facilities also include the following

Patients transferred to another Health Service also include the following

Hypertension, Atherosclerosis

Cooperative, compliant and communicating appropriately, No signs of rashes, skin tears or lesions, chest

Clear on ausculation.

date & sign

Consider complex discharge planning

Referrals/action (P)

Provider details include: Admission notification Discharge notification

service provided date & sign

07/03/2018 Relatives

04/03/2018

Cholecystitis

Chelsea Bassett Darren Roberts Chelsea Bassett

04/03/2018

GENERIC ADULT PATIENT ADMISSION &

DISCHARGE SCREEN

Referrals/action (P)YES

Home DD Cupboard Drug Room

N/A

Describe Items

(Do not tick here, Description must be provided)

Returned

Darren Roberts

N/A

075486 075486 ROBERTS Darren 25 Happy Street CAIRNS 4860 23/11/1968 John Smith

Clinicial file

A copy of these orders must be place in the

24 hours if possible

N/A

(Date & Sign)Home Patient Safe

Please Tick Location N/A

SIMULATED HOSPITAL SIMULATED HOSPITAL

UR NUMBER UR NUMBER

SURNAME SURNAME FIRST NAME FIRST NAME ADDRESS ADDRESS

DATE OF BIRTH DATE OF BIRTH DOCTOR DOCTOR

5. INFECTION CONTROL 13. DEPRESSION

MRSA/VRE Clostridium difficille/Other MRO P Swabs as per policy  Doctor Notified 

Gastroenteritis P Infection control 

Acute Respiratory Infection/Influenza P Infection control 

Other Infection/Infectious disease P Infection control 

Is isolation required? P Infection control 

6. MEDICATIONS

Does the patient have any allergies? P 14. ACTIVITIES OF DAILY LIVING

If Yes, what type? Alert Sheet  ID band 

Is patient taking more than 5 medications? P Medication Chart 

Does patient use a dosette or webster pack? P If yes, Pharmacy Review  Referral

Does patient understand current medications? P Name of local Pharmacy:

7. BLOOD AND BLOOD PRODUCTS OT 

Is the patient likely to receive blood products this P Details of any Transfusion Reaction Physio 

admission?

Has the patient ever had ablood product P

transfusion?

If yest to the above, has the patient ever had a If Yes, noted on Alert Sheet 

transfusion reaction? Please comment if Yes, noted on IPM  15. ELIMINATION

9. COGNITION FWT/MSU 

Does the patient have a history of dementia? P Social Worker 

is the pateint at risk of wandering? P Occupational Therapist 

Is the patient confused? P Continence Clinic 

Is the patient disorientated? P

AMTS Score:

10. PAIN / DISCOMFORT Dietitian 

Does patient experience pain or discomfort? P Pain Service Referral 

Pain is Chronic  Stomal Therapist 

Acute 

Describe location, severity & life interference on care plan Date of next replacement

11. SKIN INTEGRITY

On admission does patient have any skin tears, Podiatry  16. MOBILITY/FALLS

pressure ulcers, wounds or blisters (circle) Dietitian  No Lift/Bariatric Plan 

Complete incident report and woudn chart.  Wound Consultant 

Braden Screen completed? P Score Occupational therapist 

If Braden score is ≤ 12 a Comprehensive skin assessment must be Physiotherapist 

undertaken within 8 hours (tick box when completed)  Photograph of Wound?  Physio  OT 

12. NUTRITION

Does the patient have any food allergies? P Notify Kitchen 

Allergy Type: Alert sheet 

Diet type: Please document daily in care plan Doctor 

Does patient have difficulty swallowing? P Speech Pathology 

MALNUTRTION SCREENING TOOL

Has the patient los weight No 0 P

recently with out trying? Unsure 2 Add score  Does the patient require the following items? If needed do they have Do items need to be Complete MR 118

Yes, 1 - 5kg 1 if 2 or more, refer to dietitian and them? brought in?  P

Yes, over 5kg 2 comemnce upon HEHP Diet Yes No Yes No

Has patient been eating poorly No 0 P Dietitian  Glasses Family and friends asked Falls prevention

because of decreased appetite? Yes 1 HEHP Diet  to bring required items in booklet

Non slip footear Date discussed provided

(if risk) 

Mobility Aids

ROBERTS Darren 25 Happy Street CAIRNS 4860 23/11/1968 John Smith

ROBERTS Darren 25 Happy Street

If concerns exist regarding safety with mobility or

function, refer to:

Complete Falls Prevention Screen, Assessment &

Strategies (MR118) if patient ≥ 65 years or Falls risk is

identified on ALERT SHEET or Yes to 2 or more of the

mobility & falls questions

Is the patient in need of frequent toileting?

NO YES

is the patient bariatric?

Has the patient had unexpected falls within the last 6

months

Does the patient have an unsteady/unsafe gait?

Is the patient agitated/confused/disorientated? (see

section 9)

Does visual impairment impact on everday function such

that the patient is considered unsafe?

Referrals/action (P)

Have incontinence of urine or faeces? (circle)

Use continence aids? What type?

Suffer from constipation or diarrhoea?

(circle and describe strategies)

Have a Urostomy/Colostomy (circle)

Does the patient have an indwelling catheter or an

intermittent catheter?

Grooming I I Mobility

NO YES Referrals/action (P)

Does the patient have frequency, buring or pain on

voiding?

Showering/Bathing I I Toileting I I

Level of Function Pre Morbid Level of Function Pre Morbid Current

Dressing I I Eating

Current

NO YES Referrals/action (P)

SCORE Referrals/action (P)

NO YES Referrals/action (P)

if the patient is aged 65 years or older, or P in the yes column

complete Multidisciplinary delirium & cognition scfreen and stickers

NO YES Referrals/action (P)

Recent mood or energy level changes?

Recent changes in sleep patterns, significant

Yes to weight loss/decrease in section 12

Referrals/action (P)

Key: I = Independent S = Supervision A = Able to assist D = Dependent

Referrals/action (P)YES

CAIRNS 4860 23/11/1968 John Smith

N/A

075486 075486

N/A

SIMULATED HOSPITAL SIMULATED HOSPITAL