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Guide for Aged Care Home staff
Responding to a sick or injured resident
Conduct basic clinical
assessment
If resident needs
medical care….
OR
Contact:
1. GP Contact information
2. In Reach (See page 1 for hours of
service)

St Vincent’s
T: 1800 891 300

Royal Melbourne T: 0448 570 420
3. Locum medical service insert details
Any of the above services may direct
you to ring for an ambulance
November 2013
Call for an Ambulance
000
Guide for Aged Care Home staff
For basic clinical assessment of the acutely unwell resident & ringing the GP
This guide is for Aged Care Home staff to help you provide enough clinical information over the telephone for the General Practitioner to decide the course of action
for the acutely unwell resident. It does not replace clinical care protocols within your Aged Care Home e.g. relating to falls, or specific resident care plans
e.g. diabetic management. The guide may also be useful if you need to ring Hospital In Reach, other hospital services, a locum medical deputising service or an ambulance.
Step 1. General assessment
Step 2. Ringing the GP
Step 3. Leaving a message
Assess
Before ringing, have in front of you:
If you have to leave a message, include:
 Does the resident look unwell
 Drug chart including allergies
 Main symptoms e.g. distress, pain, difficulty
breathing, etc.
 Patient notes with documented vital signs
and general assessment (Step 1)
 Main physical signs e.g. alert, pale, sweating,
dehydrated, etc.
 Vital signs: pulse rate (regular / irregular),
temperature, respiratory rate, blood pressure,
blood sugar level (BSL)
 Consider resident care plan and wishes of
resident/relatives or any Advance Care
Directives
 Decide on urgency: ring the GP or wait till GP
available in-hours or call Hospital In Reach
service or call locum or discuss with hospital
ED or ring ambulance
Tell the doctor:
 Name of Aged Care Home, telephone number
and time of call
 Name of resident
 Your name and title
 Your name and title (e.g. RN, EN, PCA),
and name of resident
 Main reason for ringing
 The main reason for ringing e.g. change in
cognitive state / alertness, chest pain, abdominal
pain, vomiting, resident had a fall, suspected UTI,
palliative care, family request, etc.
 Your next course of action
 Urgency/how soon you need the doctor to
ring back
 How long problem has been present and whether
recurrent
Step 4. Action
 Who assessed the resident (name and title)
and what time
After the telephone call, document…
 Findings from general assessment (Step 1)
 Name and telephone number of GP / In Reach/
locum and time rung
 Who requested the doctor be rung
(aged care home staff/ resident/ family)
 Whether GP / In Reach/ locum will attend and
date and time expected
 What action has been taken already
e.g. pain relief, anginine etc.
... and implement
 Immediate action / instructions e.g. medication
order, monitor resident, call In Reach, call locum,
call ambulance, etc.
 Contact family as required
North East Valley Division of General Practice, Revised November 2013
November 2013
1