Hospital Transfer and Care Information(Form-1048)
Participants's Personal Information
Name:
First Name
Last Name
Take/Upload Photo of Participant:
Date of Birth:
-
Day
-
Month
Year
Date
Pension Number:
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)
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
Yes
I need someone who knows me well to be with me. I need this to be able to communicate with staff and/or remain calm and keep everyone safe
I have communication support needs (e.g., device, speech equipment, ESL, deaf/hard of hearing, blind)
I hurt myself when scared or confused
I hurt others when scared or confused
I might try to run away if I am scared or confused
I have a hard time staying still
I have physical care needs (e.g., eating, mobility, bathing)
Please select relevant documents and upload below:
Note/summary from my GP
Behaviour Support Plan
Advance Care Plan
Current medication list/Webster pack
Medication history
Mealtime Management Plan
Communication plan, related tools/aids/device
Substitute decision maker documentation
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Notes:
Health Information
Diagnosis/disabilities:
Medication chart attached
General Practitioner:
GP Phone Number:
Pharmacy Name:
Pharmacy Number:
Notes:
Healthy decisions are usually made:
On my own
With support
By my substitute decision maker
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:
Substitute Decision Maker Details (if applicable)
Name:
First Name
Last Name
Relationship:
Phone Number:
Accommodation Details:
(For contact ONLY between the hours of 5am and 9pm)
Address:
Street Address
Street Address Line 2
Suburb
State
Post Code
Phone:
Email:
example@example.com
My Communication and Support Needs:
Normally I communicate by:
Speaking
Speaking, but I don't like speaking to strangers,
Speaking, but I only have a few words I use
Using a picture, letter board or device
Facial expressions, I have no other way to communicate, and I may not be able to tell you about pain
Things you can do to help me understand:
Look at me when you speak
Speak slowly
Use pictures
Write it down
Repeat things
Use gestures
Let my caregiver or carer explain
Use simple language
As me to repeat it back
Put my hearing aid in
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 a little something to look forward to after
Get me to look away and proceed as quickly as possible
Play music or sing
Other
Physical Care Needs
Mobility
Independent
Supervision
Assistance required
Equipment (specify below)
Equipment required
Eating and Drinking
Independent
Supervision
Assistance required
Full assistance
Showering
Independent
Supervise
Assist
Dressing
Independent
Supervise
Assist
Toileting
Independent
Supervision
Assistance required
Full assistance
Urinary Continence
Yes
No
Faecal Continence
Yes
No
Behaviours
Very aggressive
Unpredicted responses
Restlessness
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 Accommodation facility 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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