please admit operation and clinical details

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Attach patient identification label (Hospital Use Only)

UR No.: Admission No.:

Surname:

Given Names:

Date of Birth: / / Gender:

Doctor:

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To be completed by Doctor. Please PRINT clearly.

Title: Name: Surname:

Date of Birth: / / Gender: Male Female Indeterminate/Intersex/Unspecified

Address:

Telephone (Wk/Day): (Home): (Mobile):

Date of admission: / /

Allergies:

Additional medical conditions:

Proposed operation/procedure/treatment:

Provisional diagnosis:

Date of operation: / / Estimated time in operating theatre:

Item numbers:

Expected length of stay: Day Only Overnight or longer Number of days:

Patient for Rehabilitation post operatively? Yes No

If yes, at St Luke’s? Yes No (please specify location):

Blood group and hold: to be attended on admission I have already arranged with:

Blood cross match: to be attended on admission I have already arranged with:

Thromboembolism prophylactic measures to be initiated on admission: Yes No

Details:

Other instructions/investigations on admission (e.g. medications, pathology, x-rays, ECG etc.):

Please note that ordering equipment is the responsibility of the surgeon.

Specific surgical equipment requirements (e.g. loan sets, prostheses, implants):

Name of company equipment ordered from:

Gap prostheses or non-rebatable item to be used: Yes No

If yes, I confirm the patient has been informed of the cost and reason for the choice of this item: Yes No

PLEASE ADMIT

OPERATION AND CLINICAL DETAILS

SPECIFIC ORDERS ON ADMISSION

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Surname:

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To be completed by patient. Please PRINT clearly. Your responses are valuable in planning your admission and stay.

Admitting Doctor:

Date of Admission: / / Date of Operation: / /

Admission Type: Overnight Day Patient

Title: Given Names:

Surname: Previous Surname (if applicable):

Residential Address:

Postal Address:


Email:

Gender: Male Female Indeterminate/Intersex/Unspecified Date of Birth: / /

Marital status: Single Married Partnered Divorced Separated Widowed

Country of birth: Are you an Australian resident? Yes No

Language spoken at home: Religion:

Do you require an interpreter? Yes No If yes, language:

Are you of Aboriginal or Torres Strait Islander origin? Yes No Both

Name: Relationship to Patient:

Address:


Second Contact/Power of Attorney: Telephone:

Name:

Address:

Telephone: Fax: Email:

Name:

Telephone: Email:

Name of Parent/Carer staying with child:

ADMISSION DETAILS

PERSONAL DETAILS

EMERGENCY CONTACT

DETAILS OF GP

DETAILS OF COMMUNITY PHARMACY

PAEDIATRIC PATIENTS

PATIENT DETAILS FORM

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Self Next of Kin Workers Compensation DVA Third Party Defence Other:

Title: Surname: Given Names:

Address:


By signing below, I declare that I am the person responsible for this account and acknowledge that I have read, understood and agreed to the financial information as outlined in the Pre-Admission Information.

Name: Signature: Date: / /

Medicare No: Medicare Reference Number: Expiry Date: /

Do you hold any of the following cards:

Health Care Card Pension Card Pharmaceutical Benefits Card

Name of Pension/Benefit: Benefit Card No:

Have you reached the Safety Net for Pharmaceuticals? Yes No Safety Net No:

Insurance Type: Private Health Fund Workers Compensation Third Party DVA Self Funded Defence

Name of Health Fund: Type of Cover:

Membership No: Do you have an excess? Yes No

Has this cover changed in the last 12 months? Yes No

Workers Comp Fund Name:

Address:

Claim Number: Date of Accident: / /

Employer Name: Telephone:

HR Manager: Fax Number:

Third Party Name: Details: Policy Number:

Serving Member of: DVA No.: DVA Card Colour:

Details of cover (white card only):

By ticking the following boxes I acknowledge that I have read and understood the information

contained within the following sections of the Pre-Admission Booklet:

Pre-Admission Information Responsibilty of Personal Items Privacy Information

Name: Signature: Date: / /

PERSON RESPONSIBLE FOR ACCOUNT

MEDICARE DETAILS

CONCESSIONAL BENEFITS

HEALTH INSURANCE DETAILS

PATIENT RESPONSIBILITY

PATIENT DETAILS FORM

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CONSENT FOR MEDICAL AND/OR SURGICAL TREATMENT

I, Dr (please print):

have discussed with this *patient/patient’s parent/guardian/person responsible the various ways of treating the patient’s present condition including the following proposed operation/procedure/treatment: (insert site name and procedure or treatment - DO NOT USE ABBREVIATIONS)

I have informed this *patient/patient’s parent/guardian/person responsible of the nature, likely results and material risks of the proposed procedure/treatment and of the matters in the section below.

Medical Practitioner’s signature: Date: / /

Print name of Interpreter (if applicable):

Signature of Interpreter: Date: / /

I,

consent to the above operation/procedure/treatment to be performed on *me/upon my child/dependant

(Patient’s name, if not self)

We have discussed the present condition and the various ways in which it might be treated, including the above procedure or treatment. The doctor has told me that: • the procedure/treatment carries some risks and that complications may occur;• an anaesthetic, medicines, or blood transfusions may be needed and these may have some risks;• additional procedures or treatments may be needed if the doctor finds something unexpected;• tissues and blood may be removed and could be used for diagnosis or management of my condition, stored and

disposed of sensitively by the hospital or service providers;• there may be recordings, photography or filming for the purposes of my clinical management;• the procedure/treatment may not give the expected result even though the procedure/treatment is carried outwith due professional care;I consent to anaesthetics, medicines, or other treatments which could be related to this procedure/treatment.I consent to information regarding my condition being shared with other health professionals involved in my caree.g shared medical practitioners, allied health staff, community services or my General Practitioner.I understand the nature of the procedure/treatment and that undergoing the procedure/treatment carries risks.I have had the opportunity to ask questions and I am satisfied with the explanations and the answers to my questions.I understand that I may withdraw my consent at any time prior to the treatment/procedure/operation.

I consent to a blood transfusion if needed OR

I do not consent to a blood transfusion

Signature of patient/parent/guardian/person responsible

Print name of patient/parent/guardian/person responsible

Relationship to patient (if applicable) Date: / /

*Delete where not applicable

PROVISION OF INFORMATION TO PATIENT To be completed by Medical Practitioner

PATIENT CONSENT To be completed by patient

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Please specify the reason for admission:

Have pathology (blood tests) been taken for this admission? No Yes Pathology provider:

Have x-rays/scans been taken for this admission? No Yes With Patient With Doctor

What is your: Height: cm Weight: kg Blood group (if known)

Are you coming from an aged care facility? No Yes

If Yes, name of facility: Telephone:

ALLERGIES AND SENSITIVITIES

No known allergies or reactions.

YES - Please document all known allergies or sensitivities e.g medications, foods, plants, tapes and dressings.

Medicine or substance Details and reaction

MEDICATIONS Tablets, capsules, puffers, patches, insulin, eye drops and creams - include any complementary therapies , vitamins or over the counter preparations.

Medication Strength Dose Frequency Medication plan/review?

Does someone assist you to manage your medications at home? No Yes

If yes, who?

RECENTLY CEASED OR CHANGED MEDICATIONS - include any complementary therapies , vitamins or over the counter preparations.

Medication Strength Dose Frequency

ADMISSION DETAILS

MEDICATION Shaded areas for staff only


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Doctor:PATIENT HISTORY FORM

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ENDOCRINOLOGY Name of Specialist/s:

Do you have diabetes? N Y Type 1 Type 2

Controlled by diet insulin tabletsIf you have diabetes, are your blood sugar levels well controlled? N Y

Do you have low blood sugar? N Y

Do you have thyroid problems? N Y

CARDIOVASCULAR Name of Specialist/s:

Do you have a history of high blood pressure /hypertension? N Y

Do you have a history of chest pain/angina? N Y

Do you have a history of a heart attack/s? N Y

Do you have a history of palpitations/heart murmur/ irregular heart beat/AF? N Y

Do you have a history of deep venous thrombosis/ pulmonary embolism? N Y

Do you have a history of cardiac implants or grafts? N Y

Do you have a history of pacemaker and/or defibrillator? N Y

Do you have a history of heart failure/congestive cardiac failure? N Y

Do you have a history of rheumatic fever/valve disease? N Y

Do you have a history of other cardiac problems? N Y

RESPIRATORY Name of Specialist/s:

Do you have a history of recent cold – cough, fever, sore throat, or runny nose? N Y

Do you have a history of bronchitis/asthma/emphysema/ chronic obstructive pulmonary disease/shortness of breath/bronchiectasis or hay fever?

N YDo you use -

nebulisers puffers home oxygen

Do you have a history of sleep apnoea? N Y Do you use a CPAP Machine? No Yes

GASTROINTESTINAL Name of Specialist/s:

Do you have a history of any gastrointestinal ulcer /reflux/hiatus hernia? N Y

Do you have a history of any bowel disorders? N Y

Do you have a history of any liver disorders? N Y

Do you have a history of hepatitis? N Y Type of hepatitis?

Do you have a stoma? N Y

PATIENT MEDICAL ADMISSION Shaded areas for staff only

Please circle the relevant answer and if YES, specify details where applicable.

PATIENT HISTORY FORM

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HAEMATOLOGY Name of Specialist/s:

Do you have a history of anaemia/iron deficiency? N Y

Do you have a history of blood disorders/bleeding problems/clotting disorder or bruise easily? N Y

Do you take blood thinners/arthritis tablets/ aspirin based medication/warfarin? N Y

If yes, what date have you been advised to stop taking this medication? _____ / _____ / _____ If you have not been given specific instructions regarding this medication, please contact your admitting doctor for instructions.

Do you have a history of previous blood transfusion/s? N Y

Date last given: _____ / _____ / _____ Reason: Any adverse reactions? Advised of any special requirements for future transfusions?

NEUROLOGY Name of Specialist/s:

Do you have a history of any neurological condition? e.g MS or Parkinson’s? N Y

Do you have a history of seizures/epilepsy /fainting/febrile convulsions? N Y

Do you have a history of stroke/TIA? N Y Any residual weakness?

Do you have any limb deficits? N Y right leg left leg right arm left arm

Do you have any speech or swallowing difficulties? N Y

Do you have a history of delirium, dementia or cognitive impairment? N Y Screen

Do you have a history of depression/anxiety or mental health disorder? N Y

Do you have a history of developmental delay? N Y

Do you have a history of neurological or developmental disorder? e.g ADHD, Autism N Y

GENITO-URINARY / RENAL Name of Specialist/s:

Do you have a history of kidney or renal disorder/dialysis? N Y

Do you have a history of bladder issues? e.g urinary frequency/incontinence. N Y

Do you have a catheter or stoma? N Y

MUSCULOSKELETAL Name of Specialist/s:

Do you have a history of arthritis? N Y

Do you have a history of back or neck problems? N Y

Do you have a history of joint replacement/s? N Y right left : right left :

Do you have any pins/plates? N Y

Other implants or devices? N Y




Surname:

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GENERAL HEALTH AND LIFESTYLE Name of Specialist/s:

Do you have a special diet? N Y Notify diet aide

Have you lost weight recently without trying? N Y Unsure

If yes 1-5kg 6-10kg >15kg Unsure

Screen

Have you been eating poorly because of decreased appetite? N Y Screen

Have you ever smoked? N Y Daily amount? Or date ceased?

Do you drink alcohol? N Y Standard drinks per/day:

Do you have a history of drug dependency? N Y

Do you use recreational drugs? N Y

Do you exercise regularly? N Y

Female patients, are you pregnant? N Y

Do you suffer from chronic pain? N Y Pain specialist?

Do you currently have any areas of broken skin? e.g scratches or wounds. N Y

Do you currently have any bruising? N Y

Do you have a history of falls or being unsteady on your feet? N Y Date of last fall: / / Screen

Do you have a history of previous or current pressure injuries? N Y Screen

CANCER TREATMENT

Have you been diagnosed with cancer? N Y

Specify: Site:Date: / / Treatment surgery chemotherapy radiotherapy

SURGICAL HISTORY/ TRANSPLANTS/ CHEMOTHERAPY OR RADIOTHERAPY Please list dates and proceedures performed.

DATE SURGERY




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PROBLEMS WITH ANAESTHETICS (Self or Family)Malignant Hyperthermia? N Y Self Family

Have you or anyone in your immediate family had a reaction to an anaesthetic? N Y

Details and reaction

PROSTHETICS / AIDS / OTHER

Visual aids? N Y Glasses Contact lenses Sight impaired Eye prosthesis Other implants e.g. lens

Hearing aids? N Y Left Right

Walking aids? N Y

Dentures? N Y

ANY OTHER MEDICAL CONDITIONS Please document any additional medical conditions below.

PREVIOUS HOSPITALISATION Have you been treated at this hospital before? N Y Year:

Have you been hospitalised for more than 48 hours within the last 3 months? N Y Dates:

Hospital:

Have you been admitted to any hospital or aged care facility outside Australia within the last 12 months? N Y Dates:

Hospital:

INFECTION CONTROL If YES, please specify

Have you travelled to a country with a current health alert in the last month? N Y

If Yes, refer to Infection Control Co-ordinator for review.

Do you have a history of infectious disease? HIV, Tuberculosis? N Y

Have you ever had a multi resistant organism? MRSA, VRE, ESBL? N Y

Do you have or have you recently had a fever with or without respiratory symptoms? Cough, sore throat, or runny nose?

N Y

Have you had vomiting and/or diarrhoea in the last 48hrs? N Y




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QUESTIONS RELATED TO CREUTZFELDT JAKOB DISEASE (CJD)

Have you had surgery on the brain or spinal cord that may have included a dura mater graft prior to 1990? N Y

If Yes, refer to Infection Control Co-ordinator for review.

Have you had two or more first degree relatives who have been diagnosed with CJD or other Prion Disease, where genetic cause has not been excluded? N Y

Have you received pituitary hormone treatment for fertility or human growth hormone for short stature prior to 1990? N Y

Have you suffered from a recent progressive dementia illness (physical or mental), the cause of which has not been identified? N Y

Have you been involved in a “look back” study for CJD, or are you in possession of a “medical in confidence letter” regarding the risk of CJD? N Y

ADVANCED CARE DIRECTIVE

Do you have an Advanced Care Directive or treatment limiting order? N Y If yes, please provide a copy on admission.

If No, would you like more information about Advanced Care Directives? N Y

Contact Name: Telephone:

DISCHARGE PLANNING (Day Patients only) Who will be taking you home and be with you for 24 hours?

Name: Relationship:

Best contact number:

DISCHARGE PLANNING (Day and Overnight Patients)

Are you over 80 years of age? N Y

Do you live alone? N Y

Do you have someone to care for you after discharge? N YName: Relationship:

Are you solely responsible for the care of another person at home? N Y

Do you currently receive community support services? N Y Name of provider:

Do you have difficulty walking? N Y

Do you require assistance with any aspects of daily living? N Y

Where do you plan to go after discharge?

How do you plan to get there?

NAME OF PERSON COMPLETING THE FORM

Name: Signature:

Relationship: Date:

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NURSE’S USE ONLY Shaded areas for staff only

ADDITIONAL SCREENING REQUIRED

Medication review or plan? N Y

Cognitive impairment screening? N Y

Malnutrition screening? N Y

Infection control review? N Y

PATIENT HISTORY REVIEWED BY

Pre-admission Nurse

Print name:

Signature:

Designation: Date:

Admitting Nurse

Print name:

Signature:

Designation: Date:

Ward Nurse

Print name:

Signature:

Designation: Date:

ADDITIONAL NOTES


Surname:

Given Names:



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please admit operation and clinical details

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