GP intervention request (routine)

Important: For care home use only

All nursing and care home staff are able to submit a GP intervention request form on behalf of their residents, who are registered patients of Orchard Surgery.

For new resident reviews, post hospital discharge reviews, weight loss, medication reviews and non urgent referrals.

GP Intervention Request – Routine

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

Current weight:

Please provide the readings below.

Systolic “Higher”

Diastolic “Lower”

Pulse

Sats

Temperature

Blood Glucose

Respiratory Rate

Other Details

Sputum Colour:

Is the patient coughing or chesty?

Yes

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

Terms and conditions *

We accept that it is our duty of care to check replies from the surgery which will be sent via email and action where appropriate

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