Form Genoe-F03 - Client Service Receipt Inventory Form (Page 2 of 4) in pdf

Form Genoe-F03 - Client Service Receipt Inventory Form Page 2

GENOE-F03

Client Service Receipt Inventory Form

Short Form (BADS-SF)

Instruc on to assess whether an admission was planned or not

Ask: “Did you know you were going to be admi ed because the doctor had asked you to come that par cular day or

for a par cular reason?” OR: “Was the admission planned in advance?”

1) If respondent says 'no' clearly, please treat this as an UNPLANNED admission and select the appropriate

response op on.

2 ) If the respondent says 'yes', ?nd out what was the reason for the admission and ensure you are sa s ?ed that

this was a PLANNED admission.

3) If the respondent is not sure, treat this as an UNPLANNED admission

In case of unplanned hospitalisa on ask the following,

Specify whether: Admission 1

Event date:

Admission 2

Admission 3

Instruc on: If an adverse event is indicated, please inform the respondent that this informa on will be shared with

clinician who will arrange to meet the pa ent t either at home or a clinic to ?nd out more about the event and o?er the

necessary support. (Tick in the box as appropriate below.)

Is permission granted to share name with clinician?

1 Yes:

0 No:

Is permission granted to be contacted on phone by clinician?

1 Yes:

0 No:

If yes, please provide phone number

In the past 9 months, have you been to a pilgrimage, holy place

1 Yes

retreat, such as to Po a or a jatra, because of your health?

0 No

If yes,

All costs

Number of

Where

please give

(include travel

nights / visits

5.1

details

and stay)

TOTAL

Form Genoe-F03 - Client Service Receipt Inventory Form Page 2