Care Home Admissions Alert
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1
2CARE HOME ADMISSIONS ALERT
To be completed for all admissions to hospital, including out patient appointments
Personal Details
Care Home
Full Name:
Name:
Likes to be known as:
Address:
D.O.B.
Age:
Tel no.
NHS Number (if known):
Contact name:
Next of Kin
G.P.
Name:
Name:
Address:
Address:
Tel. no.
Relationship
Aware of transfer? yes no
Tel no.
Admission
Community Pharmacy
Date and reason for Admission:
Name:
Tel no:
Other Information that will help us to care for your resident:
Medical history
:
(Please attach printed GP history/summary if available)
Mobility / transfer issues
Cognition / MMSE
(including any equipment sent with the
(including any behaviour management strategies):
:
resident)
Continence
:
Eating, drinking and nutrition
(including any appliances used)
(including a recent weight and any
:
swallowing difficulties)
Tissue viability
:
Communication
:
(including any skin care and wounds)
(including speech, sight, hearing)
Medication
Adapted with thanks from The Orders of St John Care Trust
Page 1 of 2
CHUMS Working Group; Version 3 – November 2011
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