Tomaree Nursing Service - Nursing Care Referral
Items Marked   **   Must Be Completed.

Referral Date:(eg 27/09/2007) Admission Date:(eg 27/09/2007)
Referred From: Reason For Referral:
Clients Surname:** Clients Given Name(s):**
Clients Address: Clients Phone No:**
Clients Mobile: Clients Fax:
Clients Email:**
Sex: Date Of Birth:
Age:
DVA Gold Card No: Health Insurance/Claim No:
LMO: Provider No:
Phone No:
Specialist: Provider No:
Phone No:
Clients Spouse / Carer: Phone No:
Client Lives Alone:YesNo
Lives With: Relationship:
Next Of Kin (1): Relationship To Client:
Address: Phone No:
Other:
Next Of Kin (2): Relationship To Client:
Address: Phone No:
Other:

History Relating To Present Admission And Care Needs

Visit Frequency Required:
Devices In Place:
 
Security Code: **
 
 

Admission Information

On admission a Registered Nurse will need to gather all the necessary information pertaining to your admission. You will be asked to read and sign the Patients Rights and Responsibilities sheet. This is your consent to allow the nurses to visit and render care in your home.

You will also be asked to sign a treatment plan or clinical pathway; this will detail the exact type of care you are to receive. You will be provided with a frequency of visits card, so you know the exact days you will be seen.

A set of patient notes will be left at your home. It is very important that these notes are kept in a safe and familiar location so the nurses have access to them at their visit. These notes are legal medical documentation and remain the property of TNS. They are not to be accessed by family members, friends, etc and they are never to be sent with ambulances, to hospital, to doctors etc. The notes must remain in your home and ONLY the Nurses of TNS are to write in them at any time.

At your admission the nurses will assess and can assist if you require further referrals to other services ie: Meals on wheels / Diabetic Educator / Occupational Therapist / Vital Call etc.


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Phone 4981 4404 or 0439 814 404