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Patient Admission Forms

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Patient Admission Forms
168 Cudmore Terrace
Henley Beach SA 5022
P 08 8159 1200
F 08 8353 4051
E reception@westernhospital.com.au
www.westernhospital.com.au
It is essential that the hospital receives
these forms as soon as possible
following consultation with your
doctor. This will help us to ensure
you are well prepared for the day of
admission. Please take the time to
read and fill out all of the pages of this
pack and return to the hospital.
2
How to find us
Western Hospital is located at:
168 Cudmore Terrace Henley Beach SA 5022
P 08 8159 1200 F 08 8353 4051
Map courtesy of Google Maps ©2013
3
Information
Western Hospital is a health services hub, providing
facilities for surgical and medical patients. It also provides a
GP Practice and a Community Pharmacy on site, along with
specialist consulting rooms.
The hospitals primary purpose is to care for you and your
needs and the staff strive to maintain a high standard of
patient care. The staff work as a team and will do their
utmost to make your stay as comfortable as possible.
Accommodation
We pride ourselves on our single room accommodation and
ensuite facilities. Every effort is made to provide patients
with their choice of accommodation, either shared or
private, but some circumstances may require us to provide
alternative accommodation.
Admission
All admissions to the hospital are arranged by your doctor.
Forms are generally provided by your doctor or you can
download the forms from our website:
www.westernhospital.com.au
Please ensure that you have discussed your procedure with
you doctor and you have signed a consent form.
The preadmission process is an important part of your
hospital admission ensuring we can confirm the details
of your admission, financial arrangements and any other
needs you may have in the planning of your admission.
Please take the time to read and complete the attached
pages of this admission document.
In order to minimise delays we request that you email, post,
fax or personally hand in your completed admission forms
at least five days prior to your admission.
Email to:
bookings@westernhospital.com.au
Post to: PO Box 81 Henley Beach SA 5022
Fax to: 8353 5041
Or drop your admission forms in to our Reception staff
Monday to Friday 7am -8pm and Saturday 8-4pm.
Preadmission service
A preadmission service for patients undergoing procedures
is provided by the hospital.
Our preadmission nurses will review the medical history
information you provide prior to your admission. Depending
on the type of surgery and anaesthetic you will be having,
you may be contacted by one of our nurses to further
discuss the information you have provided us.
If you do need to be preadmitted by the preadmission
nurse, you will be contacted prior to your admission date.
You may also need to visit the physio, or undergo blood
or other tests, prior to your admission. Your doctor or the
nurse will arrange these if required.
Discharge information
On the day of Discharge, patients are encouraged to vacate
their rooms by 10am to enable us to prepare for incoming
patients.
Where necessary, the planning of your discharge is
commenced at the time of your admission and the following
services may be planned and arranged:
• Equipmentyoumayneedathome
•
Home support services (Community Nursing, MOW etc.)
Day patients should arrange a pick up time with the nursing
staff upon admission.
Patient information
Our objective is to ensure that your
admission runs smoothly and that
everything is ready and organised
when you arrive at Reception on
the day of your admission. If you
have any queries about any aspect
of your admission please do not
hesitate to contact the hospital.
4
What to bring
• Details of Health Insurance Membership, Workcover,
Pension or Veterans Affairs cards, Pharmaceutical Benefits
cards, Medicare card and Safety Net Entitlement card
• SLEEP APNOEA PATIENTS please bring in your CPAP
machine with you to be checked by our maintenance
department between 8am and 4pm Monday to Friday
prior to admission day
• AllrelevantX-rays/scans
• All medication you are currently taking, in the original
packaging. Bringing your medicines to hospital with you
will assist staff to have a complete and accurate picture
of your current treatment. It may also identify any issues
you have with your medicines which can be referred to a
pharmacist or your doctor.
• Nightwear,dressinggown,slippers(ifstayingovernight)
• Personaltoiletriesandsoap
• Walking/mobiiltyaids(includingsturdyshoes)
What not to bring
• Cigarettes – Western Hospital is a NO SMOKING
environment and smoking is not permitted anywhere
in the hospital or on hospital grounds.
• Talcumpowderisprohibitedinthehospital
• Excessluggage
• Valuables–WesternHospitalstrongly recommends that
you do not bring anything of value into the hospital (e.g.
large amounts of money, credit cards if not required for
payments or items of personal value). THE HOSPITAL
DOES NOT ACCEPT RESPONSIBILITY FOR LOST OR
STOLEN ITEMS.
• Werequestthatintheinterestofelectricalsafety,youdo
not bring in electrical items with you
• We also requestthat you removejewellery, makeupand
nail polish before your admission.
Guest Wi-Fi
Wi-Fi is available in all hospital areas. All patients can log on
with no password for 20 minute sessions without any limits
to the number of sessions during your stay.
TVs, radios & phones
Televisions and radios are provided at each bed. For
overnight patients, a telephone is available in your room.
Local calls are free of charge. Cordless phones are available
for Day Procedure patients. The use of mobile phones is
permitted in some areas of the hospital. Please follow
signage and instructions from nursing staff.
Insured patients
Your account for hospitalisation will include accommodation,
theatre fees and other chargeable items in accordance with
Western Hospital’s current arrangement with your health
fund. For items and services such as pathology, radiology,
physiotherapy, anaesthetists and other doctors involved
in your care whilst in hospital, you will receive a separate
account from the provider. You should discuss these fees
with your doctor prior to and during your hospitalisation.
On receipt of your admission paperwork our staff will
complete a health fund check, however it is also important
that you contact your health fund to confirm your level of
cover and whether you have an excess, co-payment or
exclusion on your policy. All excesses and co-payments
for all patients (including Day patients) are payable on
admission. If these payments are not received prior to or
on the day, your procedure will be cancelled. Payments
can be made over the phone with your credit card.
Intheeventthatyourhealthfundrejectsyourreimbursement
claim for any reason, the hospital will seek to recover any
amounts outstanding from you.
In this admission pack you will find a financial consent
declaration. Please read this information carefully as it
details your financial obligations.
Self-insured patients
If you are self-insured (i.e. you do not have private health
cover) you will be required to pay an estimated amount of
the total account on or prior to your admission. Other costs
which may be incurred during your stay will be payable
when your account is finalised on discharge.
Patient information
DAY OF ADMISSION: To enable staff
to prepare you adequately for your
procedure and to allow time for
any anaesthetic consultation, there
may be a waiting time between your
admission and procedure time.
5
WorkCover/ThirdParty
Insurance Patients
If you are a WorkCover or Third Party Insurance patient,
Western Hospital will require written approval for your
admission from the relevant insurance company on or prior
to your admission day.
Pharmacy
Western Pharmacy is located onsite and can fill all of your
prescriptions. It serves the community of the western
suburbs and provides professional medication advice.
A Clinical Pharmacist is available whilst you are in hospital
for advice and counselling as required.
You will be required to pay for any discharge medications
on your day of discharge.
Visitors
Normal visiting hours are 11am – 8pm. Please speak to
the nursing staff about visiting outside of these hours. We
ask you be mindful of other patients comfort when visitors
come in to see you.
Mail
Mail will be delivered to you daily, the correct address to
inform your relatives is:
c/-WesternHospital
168 Cudmore Terrace, Henley Beach SA 5022
Or they can email to:
reception@westernhospital.com.au
Children in hospital
Parents may visit their children at any time. Arrangements
can be made for one parent to be accommodated with their
child. If your child has a special toy etc. please bring it with
him/her.
Special diets
If you require a special diet please inform us as soon as
possible so we can meet your needs.
Free parking
Ample parking space is provided on the hospital grounds.
Please ensure your vehicle is not parked in unauthorised
areas.
Interpreter service
If the services of an interpreter are required, please contact
the hospital prior to admission so that the necessary
arrangements can be made.
Courtside café
Our café located on the ground floor, is open Monday
to Friday, 8am – 5pm. Thereis a widerange of food and
beverages available for purchase.
Further information
If you require any further information or you would like to
talk to someone about your planned hospital stay, please
contact us on 8159 1200 and ask to speak to our Patient
Services Coordinator or Pre-admission Nurse.
Patient information
You can find out more information
about Western Hospital and its
services by visiting our website:
www.westernhospital.com.au
Log onto our Facebook page:
Western Hospital SA
or follow us on Twitter:
@WesternHospitSA
6
Respecting your privacy
The privacy of your personal information is important to us
at Western Hospital and we are committed to ensuring it
is protected. Western Hospital complies with the National
Privacy Principles under the Commonwealth Privacy Act
1988andallotherstate/territorylegislativerequirementsin
relation to the management of personal information
.
Collecting of
personal information
In order to provide you with the health care services that
you have requested when you become a patient with us, we
need to collect and use your personal health information. If
you provide us incomplete or inaccurate information we may
not be able to provide you with the services you are seeking.
When you become a patient of Western Hospital, a medical
record is created and it includes personal information such
as your name and contact details, as well as information
about your health problems and the treatment you received.
Each time you attend the hospital, we will update your
medical record, collecting information necessary for the
provision of healthcare and services for you.
Our staff will always endeavour to be sensitive to your needs
when obtaining personal health information. However,
they are also committed to acting in your best interests
by making a thorough assessment of your condition and
medical history.
Protecting your
personal information
In addition to complying with all relevant privacy and
confidentiality legislation, Western Hospital has strict
policies and protocols with respect to the collection, use,
disclosure and storage of patient information.
We have
taken measures to ensure both paper based and electronic
information on our computer system are stored securely.
Only authorised personnel have access to your information.
Using and disclosing
your personal information
During your hospitalisation there may be occasions when
we may be obliged to or authorised under law to disclose
patient information, regardless of your consent, including
subpoena of records for legal action, mandatory reporting to
government authorities (such as registration of births, deaths,
diseases and treatments) or reporting information about care
provided as required by the SA Department of Health.
In order for us to provide care and services for you, we
may also use your information where necessary for the
management of our hospital, to liaise with your health
fund, and Medicare as necessary, and for activities such as
quality assurance processes, accreditation, audits, risk and
claims management and education of health professionals
involved in your care and treatment.
Accessing your
personal information
You have a right to have access to the health information that
weholdinyourhealthrecord,subjecttosomeexceptions
allowed by law. You can also request an amendment to your
health record should you believe that it contains inaccurate
information. For more information about accessing your
records, please contact our Privacy Officer.
If you have a complaint
about privacy issues
If you have a complaint about our information handling
practices, you are encouraged to speak directly to our staff.
If after this you feel the matter has not been addressed,
please contact the Office of the Australian Information
Commissioner (OAIC) who have complaint handling
responsibilities under the Privacy Act 1988 (Cth).
Contact them on 1300 363 992, post to GPO Box 5218
Sydney NSW 2001 or visit their website www.oaic.gov.au
Your privacy
Included in this pack is a Privacy Consent Form, which we ask you to read, sign and
return with your paperwork. If you have any further questions please contact us and will
be happy to answer them for you.
7
As a consumer of healthcare services at Western hospital
you have specific rights and responsibilities regarding your
care and treatment.
Western Hospital’s Rights and Responsibilities Charter
recognises that people receiving Care and people providing
care all have important parts to play in achieving healthcare
rights. These rights and responsibilities are essential to
make sure that care provided is of a high quality and is safe.
You have the right to
• Have access to the best and most appropriate care
available for your needs
• Beshownrespect,dignityandconsideration
• Beinformedofallaspectsofservices,options,treatments
and costs in an open and clear way
• Beincludedindecisionsandchoicesaboutyourcare
• Privacy and condentiality of your personal and health
information
• Asktheidentity,professionalstatusandqualicationsof
any healthcare worker providing care and services
• Express your concerns or provide feedback by making
suggestions or complaints and you have the right to have
these addressed.
You have the responsibility to
•
Answer questions about your health openly and completely
• Complywithprescribedtreatments,seekingclarication
if you are unsure
• Inform staff and your doctor if you have any concerns
about your conditions
• Discusswithyourhealthcareprofessionalsifyouwishto
refuse treatment
• Respectthedignityandrightsofotherpatients,visitors
and hospital staff
• Contact the hospital should you wish to postpone or
cancel your admission or if you are unable to arrive at the
scheduled time
• Respecthospitalproperty,policiesandregulations
• Finaliseyouraccountspertainingtoyourhospitalisation
• Directanycomplainttoastaffmembersothatappropriate
steps can be taken to address your concerns.
Complaints, compliments
and feedback
We welcome any feedback relating to any aspect of the
care and services you receive at Western Hospital, and we
encourage you to complete the Patient Feedback Surveys
available in all areas.
If you have particular concerns we encourage you to speak
to our staff directly whilst you are in hospital or contact our
Chief Executive Officer:
Western Hospital
168 Cudmore Terrace, Henley Beach SA 5022
P 8159 1200 F 8353 4051
We will endeavour to resolve your concerns with you and
we welcome the opportunity to improve the safety and
quality of our care and services.
Should you feel that the matter needs independent review,
we encourage you to contact the Healthcare & Community
Services Complaints Commission: call 1800 232 007 or visit
their website www.hcscc.sa.gov.au
Rights and responsibilities
The brochure ‘10 Tips for Safer
Healthcare’ is available in
compendiums in your room. If you
would like further information you can
access it at The Australian Commission
for Safety and Quality in Health Care
website at: www.safetyandquality.
gov.au/publications/10-tips-for-safer-
health-care/
Look for our Patient Feedback Survey
Forms, we would love to hear what
you think of the care and service you
received. We welcome any opportunity
to hear from you so that we can
continue to improve the quality and
safety of the care we provide.
8
If you have any questions at all please do not hesitate in contacting your doctor, our
hospital reception staff or preadmission nursing staff.
Patient notes
9
OFFICE USE ONLY
UR No:
Please complete and return Admission Form and Patient History to Western Hospital promptly
prior to your admission. You can do this by post, in person to our reception, or by emailing to:
bookings@westernhospital.com.au
PLEASE PRINT CLEARLY AND COMPLETE ALL SECTIONS OF THE FORMS. YOUR RESPONSES
ARE VALUABLE IN PLANNING YOUR ADMISSION AND CARING FOR YOU DURING YOUR STAY.
ADMISSION DETAILS
DATE OF ADMISSION
DATEOFOPERATION/PROCEDURE
ADMITTING DOCTOR
REASON FOR ADMISSION
HOSPITAL STAY
OVERNIGHT DAY
PERSONAL DETAILS
TITLE
SURNAME
PREVIOUS SURNAME (IF APPLICABLE)
GIVEN NAMES PREFERRED NAME
ADDRESS SUBURB STAT E
P/CODE EMAIL
POSTAL ADDRESS (IF DIFFERENT FROM ABOVE)
PHONE–HOME WORK MOBILE
DATE OF BIRTH AGE SEX: MALE FEMALE
COUNTRY OF BIRTH ARE YOU A PERMANENT RESIDENT OF AUSTRALIA? YES NO
MAIN LANGUAGE SPOKEN AT HOME?
DO YOU REQUIRE AN INTERPRETER? YES NO
OCCUPATION RELIGION
WOULDYOULIKEARELIGIOUS/PASTORALVISITWHILSTINHOSPITAL? YES NO
MARITAL STATUS:
SINGLE MARRIED OR DEFACTO WIDOWED DIVORCED SEPARATED
RACE (REQUIRED BY SA HEALTH):
CAUCASIAN ABORIGINAL TSI ASIAN OTHER
PERSON TO CONTACT (NEXT OF KIN)
TITLE SURNAME GIVEN NAME
RELATIONSHIP TO PATIENT
ADDRESS SUBURB STATE P/CODE
PHONE–HOME WORK MOBILE
ALTERNATIVE CONTACT PERSON –
PHONE RELATIONSHIP
WHO IS YOUR GP/LOCAL DOCTOR
FULL NAME OF DOCTOR
ADDRESS
TELEPHONE FAX EMAIL
Patient Admission Form
10
Patient Admission Form
PERSON RESPONSIBLE FOR THIS ACCOUNT
IS THE PATIENT RESPONSIBLE FOR THIS ACCOUNT? YES
(GOTONEXTSECTION)NO ( COMPLETE THIS SECTION)
TITLE SURNAME GIVEN NAME
RELATIONSHIP TO PATIENT
ADDRESS SUBURB STAT E
PHONE–HOME WORK MOBILE
HEALTH INSURANCE DETAILS
INSURED PATIENTS: it is recommended that you contact your health fund prior to completing this section to check
your level of cover, particularly if you have been a member for less than 12 months or have changed your cover in the
same period. Please be aware of the PRE-EXISTING CONDITION RULE. It is important that you are aware of all financial
costs relating to your stay in hospital. Please note payment methods accepted are: cash, eftpos, credit card, bank
cheque and direct deposit. Direct deposits must be made three days prior to admission. We DO NOT accept personal
cheques, AMEX or Diners cards.
HEALTH FUND NAME MEMBERSHIP NO. TABLE
CURRENT TABLE MEMBERSHIP: OVER 12 MONTHS?
YES NO LESS THAN 12 MONTHS? YES NO
DOYOUHAVEANEXCESSORCO-PAYMENTTOPAY? YES NO IF YES, HOW MUCH? $
ANY EXCESS OR CO- PAYMENT MUST BE PAID PRIOR TO YOUR ADMISSION
OUT OF POCKET EXPENSES
HASYOURADMITTINGDOCTOR/SPECIALIST/ANAESTHETISTEXPLAINEDTOYOUHISHERACCOUNTDETAILSIN
RELATION TO YOUR ADMISSION AND TREATMENT? YES NO
IF YOU ANSWERED NO, IT IS RECOMMENDED YOU TALK TO YOUR ADMITTING DOCTOR/SPECIALIST/ANAETHETIST
PRIOR TO YOUR ADMISSION TO OBTAIN INFORMATION ABOUT ANY OUT OF POCKET EXPENSES THAT MAY APPLY
SELF FUNDED PATIENTS
Please obtain information regarding item number(s) for planned procedure from your doctors’ rooms , and then contact the
hospital for an estimate of costs.
ALL COSTS FOR UNISURED PATIENTS ARE PAYABLE PRIOR TO ADMISSION AND ARE NOT COVERED BY MEDICARE
COMPENSABLE ADMISSIONS
WORKCOVER
THIRD PARTY PUBLIC LIABILITY
THE APPROVAL LETTER FOR THIS ADMISSION (FROM YOUR INSURANCE COMPANY) MUST ACCOMPANY THIS FORM
INSURANCE COMPANY DETAILS:
NAME OF INSURANCE COMPANY
CLAIM NUMBER DATE OF ACCIDENT
CONTACT PERSON PH FAX
EMPLOYER DETAILS:
NAME OF EMPLOYER
ADDRESS
CONTACT PERSON PH FAX
ENTITLEMENTS
MEDICARE NO.
NO.PREFIXINGNAME VALID TO
PENSION NUMBER EXPIRYDATE
PBS SAFETY NET CARD NO EXPIRYDATE
DEPARTMENT OF VETERAN AFFAIRS FILE NO EXPIRYDATE
GOLD/WHITE/OTHER
PREVIOUS HOSPITALISATION
HAVE YOU BEEN A PATIENT AT WESTERN HOSPITAL SINCE AUGUST 2003? YES NO
IF YES, WHAT YEAR?
HAVE YOU BEEN A PATIENT AT ANY HOSPITAL WITHIN THE PAST SEVEN (7) DAYS?
YES NO
IF YES, PLEASE STATE WHICH HOSPITAL
DATES OF HOSPITALISATION FROM TO
WERE YOU A PRIVATE PATIENT? YES NO PUBLIC PATIENT ? YES NO
11
PRIVACY CONSENT
1. I have read the information provided and am aware of the Western Hospital Policy for the management of
personal health information.
2. I understand I am not obliged to provide any information requested of me, but that my failure to do so may
compromise the quality of the healthcare and treatment given to me.
3. I am aware of my right to access the information collected about me, except in some circumstances where
access may be legitimately withheld. I understand I will be given an explanation in these circumstances.
4. I understand that if my personal and health information is to be used for any other purpose than set out in the
information provided, my further consent will be obtained.
5. I understand that I may notify the hospital of specific limitations on access or disclosure which will be
documented in my health record.
6. I consent to the handling of my personal health information by Western Hospital for the purposes set out in the
information provided, subject to any limitations on access or disclosure that I notify the hospital of.
SIGNATURE OF PERSON RESPONSIBLE*
PRINT FULL NAME DATE
*A “person responsible” means a person defined as a “person responsible” under the Privacy Act 1988 (Cwlth) with
amendements including the patient’s partner, family member, carer, guardian, close friend and a person exercising power
under an enduring power of attorney.
IN ADDITION:
IconsenttoWesternHospitalprovidingmynameandreligion/denominationtochaplainsregisteredwiththe
facility so that I may be provided with pastoral care YES NO
Should you require any assistance completing this form, please do not hesitate to contact our reception staff.
Financial & Privacy Consent Form
FINANCIAL CONSENT AND INFORMATION
1. I certify that the above information is true and to the best of my knowledge. I accept full responsibility for
accounts rendered by Western Hospital, including any shortfall in reimbursement by my health fund or any
insurance company gap following settlement by the health fund and/or insurance company.
2. I have had the financial costs of my hospitalisation clearly explained to me and understand that:
• totalcostscannotbequoted,butonlyestimatedinadvance;
• myobligation topay for my hospitalisation isindependent of anybenets I maybe ableto claim formy
private health insurance and that I will be liable for any debt collection and or solicitors fees incurred in the
collection of these accounts.
3. I understand that any excess payable under my private health insurance fund will be paid on admission.
4. I understand that I may be required to pay for some items used in theatre that may not be covered by my health
fund.
SIGNATURE OF PERSON RESPONSIBLE FOR THE ACCOUNT
The Federal Privacy Act (1988) (CwIth)
with amendements, states that your
consent needs to be obtained prior to our
collecting personal and health information
about you. Please read carefully the
Privacy Policy Information, which provides
details related to the management of your
Personal Health Information, prior to
signing this consent form.
UR: _______________________________________________________________
SURNAME: ________________________________________________________
GIVEN NAME: _____________________________________________________
D.O.B______________________________SEX: ________________________
PHONE NUMBER __________________________________________________
12
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13
Patient Questionnaire
We depend on you to provide accurate health
screening information. To help us, you are
requested to complete this Questionnaire
and return with your Admission Form to the
hospital at least FIVE days prior to admission.
Please complete all three (3) pages If you have
any queries, do not hesitate to contact the
hospital and the Admissions Officer will be able
to assist you. The information you provide will
assist us to streamline your hospital admission
and discharge, and allow nursing care to be
planned to meet your individual needs.
UR: _______________________________ DRS NAME _____________________
SURNAME:
________________________________________________________
GIVEN NAME: _____________________________________________________
D.O.B______________________________SEX: ________________________
PHONE NUMBER __________________________________________________
Please remember to bring with you all your current medication (in original labelled containers) and relevant x- rays to hospital. It
is advisable that you do not bring any valuable items into hospital. The hospital cannot take any responsibility for any valuables.
WHATISYOUREXPECTEDLENGTHOFSTAY? DAY SURGERY OVERNIGHT NUMBER OF DAYS
WHAT IS YOUR ADMISSION DATE? WHAT IS YOUR PLANNED ADMISSION TIME?
WHAT IS YOUR PLANNED DISCHARGE DATE? (F
orovernightpatients,DayofDischarge–time1000)
WHAT HEALTH PROBLEMS ARE YOU BEING ADMITTED FOR?
WHAT NAME WOULD YOU PREFER TO BE CALLED?
DO YOU REQUIRE AN INTERPRETER?
YES NO SPECIFY LANGUAGE
DISCHARGE PLANNING – please discuss any concerns you may have about your discharge with the Admitting Nurse
DO YOU LIVE ALONE? IF NO, WITH WHOM? YES NO
DO YOU RESIDE IN A HOSTEL OR NURSING HOME? (Name & contact number)
YES NO
DO YOU REQUIRE DVA TRANSPORT TO BE BOOKED?
YES NO
DO YOU REQUIRE ASSISTANCE WITH ANY ASPECTS OF DAY TO DAY LIVING?
YES NO
IF YES, PLEASE PROVIDE DETAILS:
DO YOU CURRENTLY RECEIVE ANY HOME SERVICES? (circle)
Nursing/HomeHelp/MOW/Other: YES NO
DO YOU ANTICIPATE NEEDING ANY OF THESE HOME SERVICES ON DISCHARGE?
YES NO
HAVE YOU EVER HAD AN AGED CARE ASSESSMENT? (ACAT)
YES NO
IF YES, PLEASE PROVIDE DETAILS IF YOU HAVE BEEN APPROVED FOR ANY CARE:
HAVE YOU COMPLETED ANY OF THE FOLLOWING? (tick)
Enduring Power of Attorney (Financial Decisions) Enduring Power of Guardianship (Personal Decisions)
Medical Power of Attorney (Medical Decisions) Anticipatory Directive
IF YES TO ANY OF THE ABOVE PLEASE PROVIDE A COPY TO THE HOSPITAL
DAY SURGERY PATIENTS
– if you are an overnight patient please go to the next section
You must have a responsible adult take you home and stay with you for 24 hours. Nursing staff will contact you 24- 72
hours following your procedure. If you have any concerns within this time, please ring Western Hospital on 8159 1200.
WHAT IS THE BEST PHONE NUMBER TO CONTACT YOU ON?
HAVE YOU ORGANISED HOME SUPPORT OVERNIGHT?
YES NO
HAVE YOU ORGANISED AN ESCORT AND TRANSPORT FOR DISCHARGE?
YES NO
NAME OF THE PERSON TAKING YOU HOME? WHAT IS THEIR PHONE NUMBER?
RELATIONSHIP TO PATIENT?
DAY SURGERY PATIENT/CARER DECLARATION:
I, _____________________________________________ have organised a responsible adult to care for me for the 24 hours following
mysurgery/procedureandwillabidebytheinstructionsthatwillbegiventomebythenursingstaffand/ormedicalofcer.
SIGNATURE DATE
MEDICATION HISTORY – please ensure you provide details of your allergies or sensitivities
ALLERGIES/SENSITIVITIES Nil Known
ADVERSE REACTION
EXAMPLE:Penicillin/Tapes/Food EXAMPLE:Rash/Nausea/Vomiting/Anaphylaxis
DOYOUHAVEALATEX(RUBBER)ALLERGY? YES NO
IF YES
, WHAT TYPE OF REACTION DO YOU HAVE?
DO YOU TAKE ANY ANTI-COAGULANT OR BLOOD THINNING MEDICATIONS?
(e.g. Warfarin, Coumadin, Plavix, Iscover, Aspirin etc)
YES NO
HAVE THESE BEEN STOPPED PRIOR TO SURGERY? IF YES
,DATESTOPPED:/ / YES NO
DOYOUTAKEANYSTEROIDS,ANTI-INFLAMMATORYDRUGSORCORTISONE/PREDNISOLONE
TABLETS/INJECTIONS? IF YES, NAME OF MEDICATION:
YES NO
HAVE THESE BEEN STOPPED PRIOR TO SURGERY? IF YES
,DATESTOPPED:/ / YES NO
DOYOUTAKESLEEPINGTABLETSORTABLETSFORANXIETY,NERVESORDEPRESSION? YES NO
ARE YOU TAKING AN ORAL CONTRACEPTIVE PILL? YES NO
ARE YOU BREASTFEEDING? YES NO
ARE YOU CURRENTLY TAKING ANY ANTIBIOTICS?
YES NO
DO YOU SMOKE OR HAVE YOU SMOKED IN THE PAST? IF YES, HOW MANY CIGARETTES PER DAY:
NUMBER OF YEARS A SMOKER: YEAR CEASED:
YES NO
DO YOU USE RECREATIONAL DRUGS? IF YES, WHAT TYPE AND HOW MUCH?:
YES NO
DO YOU DRINK ALCOHOL? IF YES, HOW MANY STANDARD DRINKS EACH DAY (AVERAGE):
YES NO
LIST OF CURRENT MEDICATIONS
Please list all medications you are currently taking (prescribed, over the counter, vitamins, complementary).
Please bring in original containers, no dosettes please. Supply a list if more medications are taken.
MEDICATION DOSE DIRECTIONS MEDICATION DOSE DIRECTIONS
MEDICATIONS USUALLY ADMINISTERED BY: SELF CARER
HAVE YOU HAD ANY RECENT CHANGES TO YOUR MEDICATION? YES NO
DO YOU TAKE MORE THAN 5 MEDICATIONS OR TAKE MORE THAN 12 DOSES PER DAY? YES NO
DO YOU USUALLY USE A DOSE ADMINISTRATION AID (WEBSTER PACK OR DOSETTE)? YES NO
DO YOU HAVE A LOCAL COMMUNITY PHARMACY?
YES NO
IF YES, WHAT IS THE NAME AND CONTACT NUMBER OF THE PHARMACY?
Patient Questionnaire
14
SURGICAL HISTORY
What operations or major illnesses do you have or have you had in the past? List any past operations
(including any implants e.g. pacemaker, infusaport, epidural steroids etc.) and any major illnesses.
OPERATION AND/OR ILLNESS YEAR OPERATION AND/OR ILLNESS YEAR
QUESTION STAFF USE ONLY
HAVE YOU EVER HAD AN ANAESTHETIC BEFORE? YES NO
HAVE YOU EVER HAD A SPINAL OR EPIDURAL ANAESTHETIC BEFORE? YES NO
HAVE YOU EVER HAD ANY PROBLEMS WITH ANAESTHETICS? YES NO
IF YES, DESCRIBE:
HAS ANY FAMILY MEMBER EVER HAD ANY PROBLEMS WITH ANAESTHETICS?
YES NO
IF YES, DESCRIBE:
IS YOUR ADMISSION THE RESULT OF INJURY DUE TO AN ACCIDENT? (eg sports, fall, car)
YES NO
IF YES, GIVE DETAILS OF HOW ACCIDENT HAPPENED:
MEDICAL HISTORY
WEIGHT: KG HEIGHT: CM
BMI:
STAFF USE ONLY
CVS
DO YOU HAVE ANY HEART PROBLEMS? (Irregular heart rate, murmur etc) YES NO
IF YES, DESCRIBE:
HAVE YOU EVER HAD A HEART ATTACK? IF YES, WHEN:
YES NO
HAVE YOU EVER HAD BYPASS SURGERY? (bypass, valve replacement, stent)
YES NO
IF YES, DESCRIBE:
DO YOU HAVE A PACEMAKER OR IMPLANTED DIFIBRILLATOR? (circle)
YES NO
DO YOU HAVE ANGINA?
DOYOUUSEGTNPATCH/SUBLINGUALSPRAY/TABLETS?(circle)
YES NO
IF YES, HOW OFTEN AND DATE LAST USED:
DO YOU GET SHORT OF BREATH, CHEST PAIN OR PALPATATIONS
AFTEREXERCISEORCLIMBINGSTAIRS?
YES NO
IF YES, DESCRIBE:
HAVE YOU EVER HAD HIGH
/LOW BLOOD PRESSURE? (circle applicable) YES NO
HAVE YOU EVER HAD A CVA
/STROKE? IF YES, WHEN: YES NO
IF YES, DESCRIBE ANY ON-GOING PROBLEMS:
DO YOU HAVE ANY BLEEDING
/CLOTTING/BLOOD DISORDERS? YES NO
IF YES, DESCRIBE:
HAVE YOU EVER HAD A BLOOD TRANSFUSION?
YES NO
HAVE YOUR EVER HAD ANY REACTIONS TO A BLOOD TRANSFUSION?
YES NO
IF YES, DESCRIBE:
Patient Questionnaire
15
RESP
DO YOU HAVE SLEEP APNOEA? YES NO
HAVE YOU EVER HAD SLEEP STUDIES?
YES NO
DO YOU USE A CPAP MACHINE?
(For overnight stays please bring your CPAP with you)
YES NO
HAVE YOU EVER HAD THROAT, NOSE OR LUNG SURGERY?
YES NO
IF YES, DESCRIBE:
DO YOU HAVE ANY LUNG OR CHEST CONDITIONS?
(asthma, bronchitis, emphysema)
YES NO
IF YES, DESCRIBE:
HAVE YOU HAD A COLD OR FLU IN THE PAST 2 WEEKS?
YES NO
MET
DO YOU HAVE DIABETES? INSULIN TABLET DIET CONTROLLED
Please check with your doctor regarding your diabetes care before & after surgery
YES NO
DO YOU HAVE THYROID PROBLEMS?
YES NO
IF YES, DESCRIBE:
DO YOU HAVE JAUNDICE, HEPATITIS (specify type A, B, C) OR LIVER DISEASE?
YES NO
IF YES, DESCRIBE:
DO YOU HAVE ANY GASTRIC PROBLEMS? (hiatus hernia, stomach ulcers, reflux)
YES NO
IF YES, DESCRIBE:
DO YOU HAVE ANY BOWEL PROBLEMS?
(
diarrhoea,constipation,incontinence,diverticulitis/stomas)
YES NO
IF YES, DESCRIBE:
DO YOU HAVE ANY KIDNEY PROBLEMS?
YES NO
IF YES, DESCRIBE:
DO YOU HAVE ANY BLADDER PROBLEMS?
(incontinence, frequency, catheter, urgency, burning)
YES NO
IF YES, DESCRIBE:
HAVE YOU HAD ANY RECENT UNINTENTIONAL WEIGHT LOSS?
YES NO
IF YES, COMPLETE
MALNUTRITION
HIGH RISK
ASSESSMENT
IF YES, DESCRIBE:
DO YOU HAVE ANY SPECIAL DIETARY REQUIREMENTS?
YES NO
IF YES, DESCRIBE:
Patient Questionnaire
16
MEDICAL HISTORY
STAFF USE ONLY
CVS
DO YOU HAVE A HISTORY OF BLOOD CLOTS IN YOUR LUNG?
(Pulmonary Embolism (PE))
YES NO
IF YES, WHICH YEAR:
DO YOU HAVE A HISTORY OF BLOOD CLOTS IN YOUR LEG OR ARM?
(Deep Vein Thrombosis (DVT))
YES NO
IF YES, WHICH YEAR:
HAVE YOU EVER BEEN DIAGNOSED WITH CANCER?
YES NO
IF YES
, WHICH TYPE: YEAR DIAGNOSED:
FALLS RISK
DO YOU HAVE ANY MOBILITY PROBLEMS? (arthritis, back pain, leg weakness)
YES NO
IF YES, DESCRIBE:
CAN YOU EASILY, WITHOUT STOPPING (PLEASE TICK ONE)
Walk around the house Walk up one flight of stairs
Walk up two flights of stairs (one floor) Walk up two flights of stairs (two floors)
WHAT PREVENTS YOU FROM WALKING FURTHER?
DO YOU USE ANY MOBILITY AIDS?
FRAME/STICK/CRUTCHES/WHEELCHAIR(please circle)
YES NO
DO YOU SUFFER FROM DEPRESSION OR AN ANXIETY RELATED ILLNESS,
SHORT TERM MEMORY LOSS OR OTHER MEMORY PROBLEM?
YES NO
IF YES, DESCRIBE:
DO YOU HAVE ANY CIRCULATORY PROBLEMS? (numbness, tingling, cold
hands/feet
)
YES NO
IF YES, DESCRIBE:
HAVEYOUEXPERIENCEDFAINTING OR DIZZINESS IN THE PAST 12 MONTHS?
YES NO
HAVE YOU HAD ANY FITS, CONVULSIONS OR BLACKOUTS? (epilepsy)
YES NO
IF YES, DESCRIBE:
HAVE YOU HAD ANY FALLS IN THE PAST 12 MONTHS?
YES NO
IF YES, WHEN AND DESCRIBE:
DO YOU HAVE ANY PROBLEMS WITH YOUR VISION? (limited, cataracts,
glaucoma)
YES NO
DOYOUWEARGLASSES/CONTACTLENSES?(please circle)
YES NO
DO YOU REQUIRE ASSISTANCE TO SHOWER, DRESS, GET IN/OUT OF
BED/CHAIR?
YES NO
DO YOU HAVE ANY HEARING PROBLEMS? HEARING AIDS?
LEFT
RIGHT
YES NO
DO YOU TAKE REGULAR PAIN RELIEF?
YES NO
IF YES, DESCRIBE:
Patient Questionnaire
17
MEDICAL HISTORY
STAFF USE ONLY
GENERAL
DO YOU HAVE ANY JAW OR NECK STIFFNESS? YES NO
IF YES, DESCRIBE:
DO YOU HAVE DIFFICULTY OPENING YOUR MOUTH WIDE OR HAVE
LIMITED NECK MOVEMENT?
YES NO
DO YOU HAVE ANY BROKEN, CHIPPED, LOOSE OR WOBBLY TEETH?
YES NO
DO YOU HAVE ANY CAPS, CROWNS, DENTURES OR PLATES?
YES NO
ARE YOU, OR COULD YOU BE, PREGNANT?
YES NO
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18
MEDICAL HISTORY
STAFF USE ONLY
INTEG
DO YOU HAVE ANY OPEN WOUNDS, SKIN BREAKS, FISTULAS OR STOMAS?
YES NO
IF YES, DESCRIBE:
HAVE YOU EVER HAD A MULTI-RESISTANT ORGANISM INFECTION?
(MRSA, Golden Staph, VRE) If you are unsure of this please speak to your
admission nurse.
YES NO
DO YOU HAVE OR HAVE YOU HAD ANY OTHER INFECTIONS OR
INFECTIOUS DISEASES?
YES NO
DO YOU HAVE ANY OTHER CONDITION OR INFECTIONS THAT MAY
REQUIREFURTHEREXPLANATION?
YES NO
PATIENT DECLARATION
TO THE BEST OF MY KNOWLEDGE, THE INFORMATION I HAVE PROVIDED IS TRUE AND CORRECT.
PATIENT(ORPARENT/GUARDIAN)NAME: _______________________________________________ DATE____/____/____
PATIENT(ORPARENT/GUARDIAN)SIGNATURE: _________________________________________________________________
Patient Questionnaire
Thank you for completing this questionnaire.
Please return with all of your paper work to
Western Hospital as soon as possible.
Note: If you do not have an electronic signature, please
submit the form and you will be able to sign the form at
the hospital upon admission.
19
THIS SECTION IS TO BE COMPLETED BY THE ADMISSION NURSE
ON ADMISSION DOSA/WARD
DATEOFADMISSION:// TIME: :
NAME BAND WITH CORRECT DETAILS INSITU:
YES NO
LIST OF PROSTHESIS BROUGHT IN:
VALUABLES:
HAVE THEY BEEN TAKEN HOME? YES NO N/A
LOCKED AWAY SECURELY? YES NO N/A
IFLOCKEDAWAY,CUPBOARD/ROOMNO: __________________ LOCKED IN HOSPITAL SAFE? YES NO N/A
MRSA/VRE/MRO SCREEN INDICATED? (HIGH RISK PATIENT) YES NO N/A
SWABS TAKEN? (ON ADMISSION OR IN PRE-ADMISSION) YES NO N/A
PRE-ADMISSION RESULTS REVIEWED? YES NO N/A
MEDICATIONS BROUGHT IN & PRE-ADMISSION DOCUMENTATION FOR MEDICATIONS CONFIRMED? YES NO
PATIENT HISTORY FORM CHECKED AND DISCUSSED WITH PATIENT OR CARER?
YES NO
NEXTOFKINDETAILSCONFIRMED? YES NO
ADMISSION NURSE SIGNATURE, PRINTED NAME & DESIGNATION
_________________________________________________
ORIENTATION BY WARD NURSE FOR OVERNIGHT PATIENTS ONLY
USEOFFACILITY&SERVICESEXPLAINED(INC.TV,CALLBELLS,CUPBOARDS,BATHROOMETC) YES NO
PATIENT HAS BEEN SHOWN THE BEDSIDE COMPENDIUM IN THE BEDSIDE DRAWER? YES NO
PHONES,VISITINGHOURS,USEOFKITCHENFACILITIESFORPATIENTS/VISITORS&DISCHARGEINFORMATION
EXPLAINED? YES NO
ADMISSION NURSE SIGNATURE,
PRINTED NAME & DESIGNATION
______________________________________________________________
DATE://
TIME: :
THIS SECTION IS TO BE COMPLETED BY THE PRE-ADMISSION NURSE
PRE-ADMISSION ASSESSMENT
DATE OF PRE-ADMISSION? IN PERSON TELEPHONE
DISCHARGE PLANNING COMMENCED?
YES NO
COMMENTS:
EDUCATION
PRE OP CARE DISCUSSED YES NO TRIFLOW PROVIDED & DISCUSSED YES NO
POST OP CARE DISCUSSED
YES NO
TED STOCKINGS PROVIDED &
DISCUSSED
YES NO
PAIN RELIEF DISCUSSED
(A
nalgesia/PCAetc)
YES NO
ADVISEDTOTAKEX-RAYSTOHOSPITAL
ON DAY OF ADMISSION
YES NO
INFORMATION BOOKLETS PROVIDED
(Pain Management, medications etc)
YES NO
PRE OP PHYSIO REVIEW ARRANGED?
DATE________/________/________
YES NO
EQUIPMENT
CRUTCHES YES NO SHOWER CHAIR YES NO
WALKING STICK
YES NO HIP CHAIR YES NO
FRAME
YES NO REACHING AID YES NO
TOILET RAISER
YES NO OTHER YES NO
PATHOLOGY
AUTOLOGOUS BLOOD.
PATHOLOGY GROUP _______________
YES NO
ECG
DATE________/________/________
YES NO
GROUP AND SAVE SERUM
YES NO
MRSA/VRE/MROSWABSARRANGED/TAKEN
YES NO
BLOODS: CBP
E/LFT
YES NO
YES NO
RESULTS RETURNED
DATE________/________/________
YES NO
URINE MC&S
YES NO
PATIENT ADVISED OF COMPLAINTS
AND FEEDBACK PROCESS
YES NO
PRE ADMISSION NURSE SIGNATURE, PRINTED NAME & DESIGNATION
____________________________________________
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Patient Admission Forms

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Completed 5 July 2021

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