Www.widgetlibrary.knowledge.scot.nhs.uk



Frail Older Persons Pathway AssessmentDemographicsLabelAge : Who accompanied patient to ED? : NoK Name : NoK RelationshipNoK Contact No : AssessorSignatureTimeSource of Referral :Date : Time :Past Medical HistoryPresenting ComplaintsFallsNumber of falls :Any loss of consciousness :L+S BP :ECG :If not for admission, referred for detailed assessment : * Yes / NoFrailty IndexClinical signs and exam findingsFrailty Criteria >65 years age with 1 or more belowResidential or nursing home residentDelirium (4AT) Dementia Impaired mobility or other functional impairmentFall in past monthIncontinenceCare PackageMEWS>3Not Part of Pilot Plan, if not part of the Pilot :BP : o2 sats on air : Temp : Respiratory Rate :Pulse : BM :Allergies :Mews Score : GCS : Exam FindingsClinical ImpressionPlan Bloods CXR ordered AWI form needed ECG If admitted/transferred Ward informed Inpatient Prescription Chart Written Patient’s own medicines transferred with patient Fluids Prescribed Repeat Blood Forms Written Transfer information if required All information to accompany patient Estimated Discharge Date …………………………………..CDU / Risk AssessmentPatient consented to display limited information about care Y / NDate : Patient responsible for own valuables Y / NDate :Patient Signature : RISK ASSESSMENTSignatureDate / TimeMRSA- mandatoryBedrails- mandatoryFalls- over 65/ history of fallsMUST- consider individual patient. Must complete within 24 hoursClearly document if in your professional judgement you decide the risk assessment is not requiredName : Chi No. Page 3Functional assessmentPre AdmissionOn assessmentMobilityIndependent Supervision requiredAssistance requiredIndependent Supervision requiredAssistance requiredStairs – internalIndependent Supervision requiredAssistance requiredIndependent Supervision requiredAssistance requiredStairs - externalIndependent Supervision requiredAssistance requiredIndependent Supervision requiredAssistance requiredWalking AidTransfers – toiletIndependent Prompting requiredAssistance requiredIndependentPrompting requiredAssistance requiredTransfers - BedIndependent Prompting requiredAssistance requiredIndependent Prompting requiredAssistance requiredTransfer - ChairIndependent Prompting requiredAssistance requiredIndependent Prompting requiredAssistance requiredPersonal Care - toiletIndependent Prompting requiredAssistance requiredIndependent Prompting requiredAssistance requiredPersonal Care - WashingIndependent Prompting requiredAssistance requiredIndependent Prompting requiredAssistance requiredPersonal Care – DressingIndependentPrompting requiredAssistance requiredIndependentPrompting requiredAssistance requiredContinenceContinentIncontinent UrineIncontinent FaecesCatheterisedContinentIncontinent UrineIncontinent FaecesCatheterisedDomestic tasks – Meal PrepIndependent Relative/friendAssistance requiredIndependent Relative/friendAssistance requiredDomestic tasks – ShoppingIndependent Relative/friendAssistance requiredIndependent Relative/friendAssistance requiredMedicationIndependent Prompting requiredAssistance requiredLevel .................MAR ChartCompliance Aid .................Independent Prompting requiredAssistance requiredLevel .................MAR ChartCompliance Aid .................WoundsPressure SoreWound SatisfactionDressingsPressure SoreWound SatisfactionDressingsAny overnight issues?Social InformationKis System Check - Do they have an Anticipatory Care Plan (ACP)? Y / N (if yes print and attach to this documentation)Swiss/Swift/Care First No.Does the person have a Care Co-ordinator?Y / N If yes contact details : Does the person have any other services involved?Y / N Details : Does the person have a Power of Attorney?Y / NDetail : Does the person have an Existing Care Package? * Yes / NoY / NAm Lunch Tea BedProvider : Overnights Total homecare hours per week :Medication Level : Does the patient live alone?Y / NLives with : Any known risk?Y / NDetails :Adult Support and ProtectionAdult Support and protection identification – Is this person an Adult at Risk of Harm?Aged 16 and over. Conduct of another person(s) is causing adult to be harmed; or the adult is harming/neglecting themselves. ‘Harm’ includes all harmful conduct, for example: physical, sexual, emotional, financial, neglect, self-neglect, self-harm, discriminatory, human right, institutional, information, domestic abuse etc.If it is known or believed that a person is an Adult at Risk, there is a legal duty to make an immediate referral to Social work, using the agreed form.Do you have concerns that the person is an adult at risk of harm?YESNODiscussion with Social work?YESNOReferral form completed (AP1 form)YESNOComments : Name : Chi No : Page : 5Discharge PlanHomecareIncrease in care requiredY / NAm Lunch Tea BedProvider : Overnights Total homecare hours per week : Date : New Care Package requiredY / NAm Lunch Tea BedProvider : Overnights : Total homecare hours per week : Date Requested : Date Commenced : Please note : provider section please input ICES, ART, Enablement or MS in this section etc., also if subcontracted out to a private provider e.g. MS – HRM should be detailedWalking AidArranged * Yes/NoEquipmentArranged * Yes/NoCommodeArranged * Yes/NoMedicationArranged * Yes/NoNotesDischarge From The Pathway Information Date Discharged from PathwayTransport ArrangedTime Called : Time of uplift :Collected by : *Red Cross / SAS / Friend or RelativeFollow up /Referred on toCommunity Wards ICES Other please specify :ChecklistICES Referral form completed :Y / NAdded to ICES Electronic BoardY / NPaperwork scanned to SymphonyY / NTransfer of paperwork arrangedY / NName : Chi No : Page : 7MULTIDISCIPLINARY MEDICINES RECONCILIATIONMust be started by admitting Clinicians within 24 hoursSource of information (use at least two sources) (Tick)PatientGP PracticePrevious Discharge LetterRelative / CarerEmergency Care SummaryRepeat PrescriptionPatient’s Own DrugsNursing Home ChartOther (please specify)GP Referral LetterAdmission MedicineAction Note : Unless otherwise indicated below, medicines should be continued on prescription sheet Name, Form, Route (specify if not oral)*tickDoseFrequencyEg 3 xSuspendAmendStopComments (if medicine suspended, amended stopped or inaccurate)PharmInitials if changeAnticholinesterase InhibitersDoseFrequencyWhen commenced*tick if Psychoactive medicationOTC / Herbal / Homeopathic / Illicit substancesFurther information eg compliance aid, recent discontinued medicinesMedicines/SubstanceReactionAdverse Reactions / Allergies None Known orAre you satisfied this medication history is complete and accurate? YES NO If NO what further action is necessary (Contact GP etc……………………………………..tick when resolved Pharmacist review signature : ………………………………………………….Date/Time………………………….. Beep No ………………….4ATThe 4A Test: screening instrument for cognitive impairment and delirium Open to : CPNOpen to : ConsultantCurrent Treatment : Diagnosis : (if known)ICD 10 Code [1] ALERTNESS CIRCLEThis includes patients who may be markedly drowsy (eg. difficult to rouse and/or obviously sleepy during assessment) or agitated/hyperactive. Observe the patient. If asleep, attempt to wake with speech or gentle touch on shoulder. Ask the patient to state their name and address to assist rating. Normal (fully alert, but not agitated, throughout assessment) 0 Mild sleepiness for <10 seconds after waking, then normal 0 Clearly abnormal 4 [2] AMT4 Age, date of birth, place (name of the hospital or building), current year. No mistakes0 1 mistake 1 2 or more mistakes/untestable2 [3] ATTENTION Ask the patient: “Please tell me the months of the year in backwards order, starting at December.” To assist initial understanding one prompt of “what is the month before December?” is permitted. Months of the year backwards Achieves 7 months or more correctly 0 Starts but scores < 7 months / refuses to start 1 Untestable (cannot start because unwell, drowsy, inattentive) 2 [4] ACUTE CHANGE OR FLUCTUATING COURSE Evidence of significant change or fluctuation in: alertness, cognition, other mental function (eg. paranoia, hallucinations) arising over the last 2 weeks and still evident in last 24hrs No 0 Yes 4 4 or above: possible delirium +/- cognitive impairment 1-3: possible cognitive impairment 0: delirium or cognitive impairment unlikely (but delirium still 4AT SCORE possible if [4] information incomplete) Plan DateMDT NotesSignatureName : Chi No : Page : 9DateMDT NotesSignatureDateMDT NotesSignatureDateMDT NotesSignature ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download