Hospital Transfer and Care Information Form-1048

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 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
Upload documents listed above:

Cancel of
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 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
Should be Empty:

Hospital Transfer and Care Information(Form-1048)

Participants's Personal Information

Hospital Transfer Information

ALERTS

Health Information

Next of Kin Contact Details

Substitute Decision Maker Details (if applicable)

Accommodation Details:

My Communication and Support Needs:

Physical Care Needs

Discharge Information