Hospital Transfer and Care Information (Form-0021)
Resident's Personal Information
Name:
First Name
Last Name
Take/Upload Photo of Resident:
Date of Birth:
-
Day
-
Month
Year
Date
Pension Number:
Diagnosis/disabilities:
Medicare Number:
Hospital Transfer Information
Date of transfer:
-
Day
-
Month
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Transferred to:
Transferred by:
Reason:
ALERTS
Medical (leave blank if N/A)
Rows
Yes
I have allergies (may include food, latex, medications including general anaesthetic)
I have swallowing difficulties (Dysphagia)
I have a family history of complication with anaesthetic
Important information about my care
Rows
Yes
I need someone who knows me well to be with me. I need this person to be able to communicate with staff and remain calm
I am deaf or hard of hearing
I am blind or visually impaired
I have physical care needs (e.g., eating, mobility, bathing)
I have an EPOA or Guardian who makes all my health decisions
Attachments
Rows
Yes
Current medication list/Webster packs
Behaviour Support Plan
Advance Care Plan
Advance Health Directive
Acute Resuscitation Plan
Mealtime Management Plan
Diabetes Care Plan
EPOA/Guardianship documentation
Communication Plan, related tools/aids/devices
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Notes:
Health Information
General Practitioner:
GP Phone Number:
Pharmacy Name:
Pharmacy Number:
Notes:
Accommodation Details
(For contact ONLY between the hours of 5am and 9pm)
Address:
Street Address
Street Address Line 2
Suburb
State
Post Code
Phone Number:
Email:
example@example.com
Health Decisions
Health decisions are usually made:
On my own
With support
By my Guardian
EPOA OR GUARDIANSHIP INFORMATION
EPOA
QCAT Guardian
Office of Public Guardian
Name:
First Name
Last Name
Relationship:
Phone Number:
Next of Kin Contact Details
(For contact between the hours of 9am and 5pm, unless an emergency)
Name:
First Name
Last Name
Relationship:
Phone Number:
ABOUT ME
A little bit about me...
My health and medical needs, and things to be mindful of:
BEHAVIOURS OF CONCERN
Rows
Yes
Food related
Eating non-food items
Property damage
Physical aggression
Verbal aggression
Harm to self
Unintentional self-risk
Leaving premises without support
Refusal to do things
Repetitive or unusual habits
Offending behaviour
Comments:
MY COMMUNICATION NEEDS
Normally I communicate by:
Speaking
Speaking, but I don't like speaking to strangers
Short sentences and simple words
Using a picture, letter board or device
My supporter or carer
Facial expressions, I have no other way to communicate
Things you can do to help me understand:
Look at me when you speak
Speak slowly
Diagrams or pictures
Write it down
Repeat things
Let my supporter or carer explain
Short sentences and simple words
Use gestures
Ask me to explain it
Check to see if I understand
Speak louder so I can hear you because I am hard of hearing
To help me with medical procedures (e.g., needles, x-rays, bloodwork):
Show and tell me what you are doing
Let me ask questions
Use numbing cream for needles
Be quiet so I can concentrate
Remind me to take deep breaths
Tell me how well I am doing
Hold my hand
Remind me to count to 10
Suggest something to look forward to after
Get me to look away and proceed as quickly as possible
Play music or sing
MY SUPPORT NEEDS
Rows
Manages own medication
Assistance with medication required
N/A
Comments
Medication
Rows
Manages own BGL
Assistance with BGL required
N/A
Diabetes Care Plan attached
Comments
Blood Glucose Level Monitoring
Rows
I have difficulties eating, drinking or swallowing
N/A
Mealtime Management Plan attached
Comments
Eating, Swallowing or Dysphagia
Rows
Independent
Walking stick
Walker
Wheelchair
Comments
Mobility
Rows
Full assist
Partial assist
Prompt
N/A
Comments
Transfers
Rows
Full assist
Partial assist
Prompt
N/A
Comments
Showering
Rows
Continent
Incontinent
Use of continence aids
Comments
Toileting
Rows
Full assist
Partial assist
Prompt
N/A
Comments
Oral Care
Rows
Full assist
Partial assist
Prompt
N/A
Comments
Dressing
Rows
Full assist
Partial assist
Prompt
N/A
Comments
Grooming (hair, makeup, shaving)
RISK MANAGEMENT
Rows
What is the risk
Risk Rating
Mitigation Action, Task
Responsibility
Risk One
Low
Medium
High
Very High
Risk Two
Low
Medium
High
Very High
Risk Three
Low
Medium
High
Very High
Discharge Information
Date of discharge:
-
Day
-
Month
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Destination of transfer:
Mode of transport:
QAS transport
Taxi Voucher
24 hour notice for Avalon Village supports (if applicable)
Relative/friend
Have any of the following been supplied by the hospital? If not, FOLLOW UP REQUIRED.
Discharge summary
Allied health documents
Medication scripts
Transfer of Care summary
Nursing summary
Care Plan
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