Assistance with Medication (Form-1059)

ASSISTANCE WITH MEDICATION REQUEST (Form-1059)

In accordance with Queensland Government’s Guideline for Medication Assistance Personal Care Services - Additional Fees and Charges Apply
Participant's Details
Name*

First NameLast Name
Date*

DayMonthYear
Date
I hereby request management/staff of Australian Quality Care to assist me with my medication as prescribed by my medical practitioner. I also understand that:
- In accordance with Section 8 of the Residential Services (Accreditation) Regulation 2018, Australian Quality Care will follow the principals of the seven ‘rights’ for safe medication administration that have been developed within the healthcare sector and are widely used. They are:
  
  1. Right person
  
  2. Right medication
  
  3. Right dosage
  
  4. Right time
  
  5. Right route
  
  6. Right to refuse
  
  7. Right documentation
- this means assisting me to access appropriate non-prescription medication in accordance with the directions provided by the manufacturer.
- this means assisting me with alternate medications recommended by my medical practitioner and/or pharmacist.
- Australian Quality Care is authorised to store such medication safely in a locked area within the facility.
- my prescriptions can be given to the pharmacist as required.
- if I am not present at the agreed time and location to receive assistance with medication, management/staff will make all reasonable efforts to locate me. Third parties Australian Quality Care may contact include family, friends, government agencies and emergency services. If unfound, Australian Quality Care may report to the appropriate people, clinics and/or medical practitioners immediately.
- should I choose to take my medication back to my room to administer later, I do so at my own risk, and staff may notify my medical practitioner.
- should I miss a dose for any unplanned reason, or if I refuse to take the prescribed medication, I do so at my own risk, and that staff can notify my medical practitioner.
- should I experience any problems with swallowing, it is my responsibility to make staff aware of these issues.
- if I experience acute or persistant swallowing problems when taking my medication, or eating or drinking, Australian Quality Care may contact my GP or health professional for assessment. This may include assessment of my current medications, and/or the need for a Mealtime Management Plan.
Signature of Participant

*Or signature of person acting on authority under Guardianship Administration Act 2000 or Powers of Attorney Act 1998 for the person named above, OR an Informal Decision Maker (must have an Informal Decision Maker Details Form-1066 signed) for the person named above.
Name*

First NameLast Name
Signature*

Clear
Date*

DayMonthYear
Date
In the presence of (Witness)
Name*

First NameLast Name
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

ASSISTANCE WITH MEDICATION REQUEST (Form-1059)

Participant's Details

Signature of Participant

In the presence of (Witness)