Galanos Nursing Home Care Plan | Webform Portal

St Wulfstan Surgery - Galanos House Nursing Home Care Plan

email

Name of Nursing Home *

Patient's Name *

NHS Number

Permissions

If the patient has capacity, do they give permission to share the care plan with appropriate people (eg Out-of-Hours and hospital)?

ONLY ANSWER THIS QUESTION IF THE PATIENT DOES NOT HAVE CAPACITY: Has the carer given permission to share the care plan with appropriate people?

Has the patient or carer given permission to share the clnical inofrmation with the multidisciplinary team (district nurse, social services, macmillan etc)?

Next of Kin

Name *

Address *

Phone Number *

Relation to patient *

Key Action Point

What Intervention is needed to support the patient in case of emergency, eg pain relief, antibiotics

Other Relevant Information

If seriously ill, what is the preferred place of care

If Other - please give details

Is a Care Plan in place to anticipate what to do in case of serious deterioration in health? *

Does the patient need emergency medication at home (eg antibiotics, glucogel)

If yes, has it been supplied?

If appropriate, is there a DNAR/RESPECT form in place?

Are there any special communication needs?

Are there any other physical or medical needs (eg mobility, dementia etc)?

Proxy Access

Does patient give consent for proxy access to medical records? *

Sign Off

Signature and Name of person completing the care plan *

Tap or click on the signature above to sign