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Consultation with care provider Placement

Use this tool every time you visit or call the facility. It will structure your conversation with the care provider to ensure you are obtaining all of the updated information on the overall functioning of your loved one. It is helpful to find out who the best person is for you to contact about how your loved one is doing (charge nurse, administrator, owner, etc.). If you develop a relationship with this person, it will make the communication easier. You may also want to ask if there are times of the day that are better for you to call (i.e.: the staff may not have as much time to talk on the phone during mealtime, when they are administering medications or during shift changes). Facility: _________________________________________________________

A

Address: ________________________________________________________ Phone: _________________________ Fax: ___________________________ Email: __________________________________________________________

IS

Date of visit or phone call: __________________________________________ Care provider you spoke with: _______________________________________

IS

Event precipitating visit or phone call, if any and/or your reason for the call: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

TH

Ask the care provider how your loved one is functioning in the following areas: Physical functioning

Ambulation/falls: ________________________________________________________________ ________________________________________________________________

Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST Š2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without prior written permission.


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Continence: ________________________________________________________________ ________________________________________________________________ New Medication and or regime (dosing, time of day, etc.): Purpose

Dosage

Side effects

Time of day

IS

A

Medication

Diet, nutrition and eating: ________________________________________________________________ ________________________________________________________________

TH

IS

Consultations with specialist (physiotherapist, occupational therapist, social worker, etc.) ________________________________________________________________ ________________________________________________________________ Tests requested and purpose: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST Š2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without prior written permission.


Cognition and behavior:

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Test results discussed: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

Mood: ________________________________________________________________ ________________________________________________________________ Behavior: ________________________________________________________________ ________________________________________________________________

A

Memory: ________________________________________________________________ ________________________________________________________________

IS

Confusion: ________________________________________________________________ ________________________________________________________________ Interaction with other residents: ________________________________________________________________ ________________________________________________________________

IS

Participation in activities: ________________________________________________________________ ________________________________________________________________

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Are there any changes from my loved one’s baseline level of functioning that I should be aware of? ________________________________________________________________ ________________________________________________________________ Recommendations given: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST ©2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without prior written permission.


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Facility follow up requested: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

TH

IS

IS

A

Your responsibilities for follow up: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST Š2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without prior written permission.


Consultation with the Care Provider - Placement