MEDICAL TREATMENT FORM
SERVICE RECIPIENT NAME:
ADDRESS:
DOB:
STAFF ATTENDING:
DATE OF VISIT:
PRACTITIONER (DR, Physio, Podiatrist, Dentist, OT) :
HEALTH ISSUE (to be completed by the person making the appointment):
PRACTITIONER’S NOTES (DR, Physio, Podiatrist, Dentist, OT):
TREATMENT ORDERED:
FOLLOW-UP REQUIRED:
MEDICATION CHANGES ARE REQUIRED (please circle)
With next
URGENT
IMMEDIATE
pack
delivery
delivery
within 24 hrs
within 12 hrs
DOCTOR’S NAME:
CRITICAL
delivery
within 2-4 hrs
SIGNATURE:
Staff attending the medical appointment is responsible completing the following after a visit to
inform other service providers of outcomes.
Please ensure that the practitioner’s instructions are clear to you and he has noted any
special conditions related to taking medications or applying lotions. These will need to
appear on various charts provided by the pharmacy.
Complete the checklist below before leaving the practitioner’s room (preferably clarify with the practitioner whilst you
are still in the room)
Outcomes of medical appointment:
YES
NO
Has new medication been prescribed?
Has name and method of application been explained to you by the
practitioner?
Does the recipient require another appointment?
Does the recipient require any tests?
If yes, when is test required? _____________________________
blood test □
xray □
Complete once back at residence (please X each box when the task is completed)
Fax Page 1 of the Medical Treatment Form and prescription(s) to Pharmacy.
Phone Pharmacy to confirm that they have received the above.
Inform day placement of medication changes relevant to them.
Record the nature of the changes in the home report book in red.
Enter any new appointments in necessary in the home diary.
Enter details of changes in Residents Personal Health Diary electronically if possible
and send as an attachment to the COORDINATOR – or enter by hand if necessary.
File the Medical Treatment Form in the Service Recipient’s medical file.
STAFF SUMMARY NOTES:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________
OTHERS INFORMED (Family, Coordinator etc)
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
____________________________
STAFF NAME: _____________________________
SIGNATURE:________________________________