Facility Information
Patient Information Fall Description: Provide information on whether the fall was witnessed, a head strike occured, whether the patient is on anticoagulants and injuries presented
Pain Description: Location of pain, timeframe in which pain ocurs (days, weeks or months), value on the Abbey Pain Scale
Skin Integrity Description: Location, whether a bruise, pressure injury, acute skin tear, chronic wound, rash, etc. Whether a wound chart commenced
Behaviour Change Description: How long has it been present (days, weeks or months), is there a reduced level of conciousness, chang in usual behaviour or personality, verbal or physical agression.
Infectious Disease Description: type and whether the resident has consented for antivirals
Weight Description: weight loss or gain, weight today, weight the previous 3 months, has there been a dietician review referral
Add additional context or GP/RN requests here:
Signature Geriatric Care Australia collects information for the primary purpose of providing quality healthcare. We ask for personal details and a full medical history so that we may properly assess, diagnose and treat illnesses and be pro-active in healthcare delivery. We will also collect, hold, use and disclose the information you provide in accordance with the Privacy Act 1988 and Australian Privacy Principles (March 2014).
I confirm that I have the authority and appropriate permissions to share the patient’s information provided in this form. The information is accurate and complete to the best of my knowledge. I understand this request is for clinical support from GCA Primary Care, and I will continue to monitor the patient and provide necessary immediate care as appropriate while awaiting a response.
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Thank you for escalating your concerns. The GCA primary care clinical coordinator will be in contact within the appropriate timeframe
