MID ESSEX CCG RED BAGS PATHWAY
Care Home - Health and Care Summary Record Form
|Date of admission to Care Home: |
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|This form was initially completed on: (DD/MM/YYYY) |
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|Please note- This form relates to care home information. This may already be held in another form and can be photocopied to avoid duplication. If |
|information in this form has been updated since the original completion, please note in individual sections. |
|Allergy Information |
|Does the resident suffer from any allergies (including drug allergies)? Yes/No |
|If Yes, please list the allergies below: |
|Resident’s name: |Date of birth: |Gender: |
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|Preferred name: | | |
|Is there a legal Power of Attorney for: | | |
|Health and Welfare?: Yes/No |Property and Finance?: Yes/No | |
|Name: |Name: | |
|Contact details: |Contact Details: | |
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|Funding arrangements (CCG/Local Authority/Self-funder/Other)? | |
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|Religion / Spirituality / Culture: | |
|Details of GP (in case clarification required regarding medication, PMH): | |
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|Other key professionals involved in care (please give name, role, and contact details): | |
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|Is there a current DOLS in place? Yes / No | |
|Is there a named IMCA or Advocate? Yes / No | |
|If yes, provide a name and contact details: | |
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|Safeguarding |Updated on: | |
|Are there any on-going safeguarding concerns? Yes / No | |
|Comments / actions: | |
|Past medical history |Updated on: |Care Home|
| | |- Health |
| | |and Care |
| | |Summary |
| | |Record |
|Relevant past medical history including any medical devices (e.g. ICD/pacemaker) or prosthesis: | |
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|Any recent illness or treatment? | |
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|Medications |Updated on: | |
|Please attach a copy of the MAR chart for current prescribed medicines | |
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|What is the method of administration of medication e.g. liquid / covertly / crushed? | |
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|Is the resident on oxygen therapy? Yes / No | |
|If yes, at what level/type of oxygen: | |
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|Is pain a particular issue for this resident? Yes / No | |
|If yes, please provide further information including any existing actions to manage this: | |
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|Infection Prevention and Control |Updated on: | |
|Is there an infection risk e.g. MRSA, C.Diff? Yes / No | |
|If yes, please specify: | |
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|Please give details including recent test results and treatments: | |
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|Behaviour and mood |Updated on: | |
|Does the resident have a history of behaviour that challenges (including resistance to care, wandering, violence & aggression, etc)? | |
|Yes / No | |
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|Please give details, including any known triggers / successful management techniques: | |
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|Please remember to include This Is Me document (or similar) in the Red Bag | |
|Sensory / communication |Updated on: | |
|Are there any communication challenges (e.g. language, hearing, etc)? | |
|Details: | |
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|Does the resident use any sensory aids (e.g. hearing aid, glasses)? Yes/No | |
|Details: | |
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|Falls and mobility |Updated on: | |
|Is the resident at risk of falls? Yes / No | |
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|Does (s)he require any assistance or mobility aids to walk/transfer? Yes / No | |
|If yes please specify: | |
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|Personal care and continence |Updated on: | |
|Does the resident use continence products? Yes / No | |
|Details: | |
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|Does the resident have a catheter? Yes / No | |
|Details OR attach catheter passport: | |
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|Does the resident have faecal incontinence? Yes / No | |
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|What is their current ability to self-care, including any necessary prompts?: | |
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|Skin Integrity |Updated on: | |
|Is skin intact: Yes / No | |
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|What is the resident’s Waterlow score? | |
|Are there any existing pressure ulcer(s)? Yes / No | |
|If yes please give details: | |
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|Are there any other wounds? Yes / No | |
|If yes please give details: | |
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|Details of any dressings: | |
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|Please ensure the body map below is completed: | |
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|[pic] | |
|Nutrition |Updated on: | |
|Please include photocopy of weight chart in the Red Bag | |
|How does the resident eat e.g. self-fed, needs assistance, enteral feeding’? | |
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|If enterally fed, please detail type, rate and hours OR to attach a photocopy of the feeding regime | |
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|Is (s)he on a soft diet? Yes / No | |
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|Is (s)he risk fed? Yes / No | |
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|Any unintentional weight loss? Yes / No | |
|Details: | |
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|Any swallowing problems? Yes / No | |
|Details: | |
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|What is the resident’s MUST score? | |
|End of life care |Updated on: | |
|Is the person known to the palliative care team? Yes / No | |
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|CNS name: | |
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|Is there an Advance Care Plan? Yes / No If yes, please attach | |
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|Is there a valid DNACPR form? Yes / No If yes, please attach | |
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|Is there any anticipatory injectable medication available? Yes / No | |
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|Is there a syringe driver in use? Yes / No If yes, include serial number and attach form | |
|This resident has given consent for healthcare professionals to share information with their Care Home, which includes personal/medical information about|
|their hospital stay: Yes / No |
|For residents without capacity to make this decision should have information shared in their best interest in accordance with the Health and Social Care |
|Act 2015(Safety and Quality) and Mental Care Act 2005. |
|Form completed by: |
|Name: |
|Qualification: |
|Signature: |
|Date and Time: |
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• To be completed when a new resident arrives at a Care Home in Mid Essex
• To be reviewed and updated at regular intervals to ensure it is up to date
• To be included within the Red Bag in an emergency if a resident is being taken to hospital
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