MEDICAL TREATMENT FORM
SERVICE RECIPIENT NAME:
ADDRESS:
DOB:
STAFF ATTENDING:
DATE OF VISIT:
DOCTOR:
HEALTH ISSUE (to be completed by the person making the appointment):
DOCTOR’S NOTES:
TREATMENT ORDERED:
FOLLOW-UP REQUIRED:
MEDICATION CHANGES ARE REQUIRED (please circle)
With next
pack
DOCTOR’S NAME:
URGENT
delivery
within 24 hrs
IMMEDIATE
delivery
within 12 hrs
SIGNATURE:
CRITICAL
delivery
within 2-4 hrs
Staff attending the medical appointment are responsible completing the following after a
doctor’s visit to inform other service providers of outcomes.
Please ensure that the doctor’s instructions are clear to you and he has noted any special conditions
related to taking any medications or applying lotions. These will need to appear on various charts
provided by the Pharmacy.
Outcomes of medical appointment: (please X each box when the task is completed)
Ensure that you know what medication the resident is to take, what dosage, when should it be
taken and under what circumstances should medical opinion be obtained.
Fax page 1 of the Medical Treatment Form and prescription(s) to Pharmacy.
Phone the Pharmacy to confirm the information has reached them.
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 necessary in 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: