6 Monthly Discretionary Funds Reporting (July - December 2021) (Preview) Microsoft Forms

6 Monthly Discretionary Funds Reporting (July December 2021) Please complete the following survey for the period 01 July - 31 December 2021.

All questions are a requirement for reporting.

Deadline for completion - 31st January 2022

* Required

1. Practice Name *

2. Your Name *

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Palliative Care For the period 01 January - 30 June 2021

3. Funds received for the period 01 July - 31 December 2021.

4. Funds Utilised for the Period *

5. Funds remaining at 31 December 2021 *

6. Number of Patients who have received Subsidised Care *

The value must be a number

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*GST EXCL* *

7. Type of services funded for Patients: * Home Visits Extended Consults Phone Consults Prescription Fees Referral Letters Aspirates RX End of Life Visits

Other

8. Average cost per Person *

9. Average number of consults *

10. Number of Patients who have Died at Home *

11. Percentage of Patients with a Care Plan

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12. Comment box - for further explanation/ information:

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High Need Discretionary Funding For the period 01 July - 31 December 2021

13. Funds received for the Period *GST EXCL* *

14. Funds Utilised for the Period *

15. Funds remaining at 31 Dec 2021 *

16. Number of Patients assisted *

17. How were the Patients assisted? *

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18. Type of services funded for Patients: Home Visits Extended Consults Phone Consults Prescription Fees Referral Letters Injections Nursing Hours Cryotherapy ECG Pharmacy Dispensing Transportation Costs Dressings Physiotherapy Iron Infusion Counselling Cervical Screening

Other

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19. Comment box - for further explanation/ information:

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Skin Surgery Fund For the period 01 July - 31 December 2021.

20. Funds received for the Period *GST EXCL* *

21. Funds Utilised for the Period *

22. Funds remaining at 31 December 2021 *

23. Number of Patients assisted *

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24. Type of services funded for Patients: * Punch Biopsy Minor Surgery Cyst Removal Wedge Resection Follow-up Appointments Dressings Skin Surgeries Injection Excision

Other

25. Comment box - for further explanation/ information:

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Authorisation 26. I acknowledge that the details entered are true and correct * Yes

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