GP intervention request – Routine – Watton Medical Practice

Please ensure all requests are received before 10:00. Coordinate all interventions with one point of contact for GP surgery to call.

Care Home: *

Room Number: *

Section

Coordinator Name:

About the Patient’s Problem

Please tell us about the problem. If the practice is already aware of this problem, please tell us what has changed: *

What outcomes are you expecting?

How long has this been a problem? *

Observations:

Readings

Did the patient decline to have their weight measured? *

Yes

No

Current weight: *

Did the patient decline to have their blood pressure measured? *

Yes

No

Please provide the readings below.

Systolic “Higher” *

/

Diastolic “Lower” *

Pulse *

Did the patient decline to have their sats measured? *

Yes

No

Sats *

Did the patient decline to have their temperature measured? *

Yes

No

Temperature *

Blood Glucose

Respiratory Rate

Other Details

Sputum Colour:

Is the patient coughing or chesty?

Yes

No

Please specify if the condition is acute or chronic:

Acute

Chronic

Further Information:

How would you like us to deal with the problem? *

Telephone

Appointment

Visit

Completed By

Your Name: *

Your Position: *

Date:

Time:

Please upload any relevant paperwork/documents relevant to this request:

Maximum upload size: 67.11MB

*

I understand that this form will be dealt with during the surgery’s opening hours

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GP intervention request – Routine

Important: For care home use only

Section

About the Patient’s Problem

Readings

Other Details

Completed By