Assistance with Medication Form-0044

ASSISTANCE WITH MEDICATION REQUEST (Form-0044)

In accordance with Queensland Government’s Guideline for Medication Assistance Personal Care Services - Level 3 Approved Accreditation - Additional Fees and Charges Apply
Resident's Details
Name:

First NameLast Name
Date

DayMonthYear
Date
REQUEST FOR ASSISTANCE WITH MEDICATION
I hereby request management/staff of Skymac 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, Skyamc will follow the recommended 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.
- Skymac 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 are authorised to make all reasonable efforts to locate me. Third parties Skymac may contact include family, friends, government agencies and emergency services. If unfound, Skymac 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 persistent swallowing problems when taking my medication, or when eating or drinking, Skymac 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 Resident

*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-0071 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-0044)

Resident's Details

REQUEST FOR ASSISTANCE WITH MEDICATION

Signature of Resident

In the presence of (Witness)