1 | p a g e · 2017-02-24 · 12 | p a g e accomodation lack of housing 13f% 13d. length of...
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Ethnicity & other related national data Ethnic category – 2001 census Country of birth
9T% 9i% 13%
Emergency contact details 918x.
Seen by GP Seen by optician Seen by practice nurse Seen by dentist Seen by CPN Seen by ambulance crew Seen by drug team Seen by midwife Seen by pharmacist Seen by podiatrist Seen by social worker Social worker involved
9N2U. 9N22. 9N2C. 9N2a. 9N1c. 9N1b. 9N2k. 9N1Q. 9N2Q. 9N26. 13G4.
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o/e blood pressure 246.
o/e pulse 242.
Urinalysis 461%
Haematuria lA45.
Blood in stools J681.
Asthma Diabetes COPD CHD (IHD) Cancer Mental illness Other
H33% C10% H3% G3% B% E%
Hospital admission 8Hd.
H/o visual disturbance Had a blackout H/o blackouts Last fit
1484. 1B66. 147D. 6676.
Breathlessness Difficulty breathing
173. 1738.
Family history Family history taken FH:DM FH:CVD FH: other diseases
12. 121. 1252. 12C. ZV1%
No known allergies History of drug allergy Latex allergy Food allergy
1151. 14L% SN531. SN58%
Assessment of risk of opioid medication storage
38B4.
Drug side effects checked No drug side effects reported
8BIZ. 661K.
Alcohol consumption 136%
Alcohol advice 8CAM%
Smoking status 137%
Smoking cessation advice 8CAL%
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Injecting drug user Drug misuse behaviour Drug misuse assessment Drug misuse assessment declined Seen in drug misuse clinic Shared care drug misuse treatment Non dependent abuse of drugs Misuse of prescription only drugs Lifestyle advice regarding drug misuse Harm minimisation regarding lifestyle H/o cocaine misuse Cocaine type drug dependence H/o crack cocaine misuse H/o Hypnotic or anxiolytic misuse Unspecified hypnotic or anxiolytic drug (benzodiazepine) dependence H/o amphetamine misuse Amphetamine or other psychostimulant dependence H/o heroin misuse Opioid type drug dependence H/o solvent misuse Glue sniffing dependence
13c0. 1V% 9kS 9s 9N1yJ 9k51 E25 E2594 67H3 678H 1T5% E242% 1T6% 1T3% E241% 1T4% E244% 1T0% E240% 1T9% E246%
Novel psychoactive substance misuse 13cM0.
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Mental health crises should be dealt with by the mental health team
Hepatitis B screening offered Hepatitis C screening offered
9Op2. 9Op1.
Chlamydia screening offered 9Oq0.
Condoms issued Contraceptive advice
8B2L.
Health education – sexual advice 679K.
Sex worker 0AL.
Currently pregnant Pregnancy test
62. 465.
Self breast examination 6795.
Cervical smear due Cervical neoplasia screening
685F. 685%
Relationship problems 13HP%
Self testicular examination 679B.
Urinary system symptoms R08%
Relationship problems 13HP%
Influenza immunisation 65E%
Hepatitis B immunisation 65F%
Immunisations 65F%
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Accomodation Lack of housing
13F% 13D.
Length of homelessness 13D8.
Under care of CMHT Under care of CDAT
9NNM. 9NN1.
Sickness benefit Benefits counselling
13O. 6743.
Adult safeguarding concern Referred to adult safeguarding team Vulnerable adult
9Ngj. 8Hkc. 133P.
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8CM%)
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