CAREPACT Medical Officer Referral Line Note:
Patient Information:
- John Smith
- 12/03/1938
- 86 years
- **Rosewood Aged Care Facility**, permanent resident
Referring Clinician Information:
- Dr. Emily Carter
- Hospital Doctor, Emergency Department
Reason for Referral:
- Patient presents with a fall and altered mental status.
Patient History:
- Current issues: Patient fell in the dining room, now confused and complaining of hip pain.
- Medical History: Hypertension, Osteoarthritis, previous right hip replacement.
- Medications: Lisinopril 10mg daily, Paracetamol as needed, Vitamin D supplement.
- Social History: Lives at Rosewood Aged Care Facility, widowed, enjoys reading.
- Allergies: NKDA
- Falls History: Patient fell in the dining room. No loss of consciousness. Patient is mobilising at baseline with a walker. No obvious injuries, but patient is complaining of hip pain. The cause of the fall is unclear. The patient's goals of care would not include neurosurgical intervention.
Examination Findings:
- GCS 14/15. Confused but oriented to person and place.
- BP 160/90, HR 88, RR 18, SpO2 96% on room air.
- Right hip tender to palpation. No obvious deformity.
- Neurological exam intact.
Investigations:
- X-ray right hip ordered. Results pending.
Patient goals of care:
- Advance Care Planning Documents: Patient has an Advance Health Directive in place, stating preference for comfort care.
- Trajectory of care: Patient wishes to remain at the aged care facility and avoid hospitalisation if possible. Focus is on symptom management and maintaining quality of life.
Management Plan:
- **Hospital Transfer**
- Discussed with family, who agree with transfer for further assessment and management of potential hip fracture.
- Notify Rosewood Aged Care Facility of transfer.
Additional Notes:
- Patient to be transferred via ambulance.
- Dr. Thomas Kelly to be notified of the patient's arrival.
CAREPACT Medical Officer Referral Line Note:
Patient Information:
- [patient name] (only include patient name if it has been explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.)
- [patient date of birth] (only include the patient date of birth if it has been explicitly mentioned in the transcript,s or clinical note; otherwise, contextual note omit completely.)
- [patient age] (include every patient with a provided date of birth by calculating the age based on the difference in years between today and the year of birth. State the age as a number followed by a space and “years")
- [patient residential aged care home] (always include this information, the name of the aged care facility or nursing home. Include the status of the patient as either permanent or respite. Check that the Residential Aged Care Home or Residential Aged Care Facility name is cross-checked against the commonwealth government list, or at least the spelling should be close to this. Ensure the RACH name is in bold)
Referring Clinician Information:
- [referring clinician name] (only include referring clinician name if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [referring clinician type] (only include referring clinician contact information if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. The type of clinician will be an ambulance paramedic, clinical hub clinician, GP, or hospital doctor. If a hospital doctor note which hospital and the department - for example, emergency department)
Reason for Referral:
- [describe the reason for referral] (only include a description of the referral if it has been explicitly mentioned; contextualise the transcript notes or clinical note; otherwise, omit completely.)
Patient History:
- [describe current issues, reasons for visit, discussion topics, history of presenting complaints etc] (only include describe current issues, reasons for visit, discussion topics, history of presenting complaints etc if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [ medical historydescribe past, previous surgeries] (only include describe past medical history, previous surgeries if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [mention medications and herbal supplements] (only include mention medications and herbal supplements if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [describe social history] (only include describe social history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [mention allergies] (only include mention allergies if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- [falls history] (only mention fall history if the reason for referral explicitly relates to a fall in the aged care home. The fall history should include if the patient has returned to their neurological baseline, whether the person is mobilising at their baseline level of mobility, including the devices they use to support their mobility. It should also be an assessment of the cause of the fall, the consequences of the fall - including injuries and potential loss of confidence, and the context of the fall - whether the person’s goals of care would include neurosurgical intervention. In those patients that are severely frail a neurosurgical procedure is unlikely to be offered or considered good medical practice and would not usually be recommended)
Examination Findings:
- [describe examination findings] (only include describe examination findings if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Investigations:
- [list investigations and results] (only include list investigations and results if it has been explicitly mentioned in the transcript, contextual notes or clinical note; otherwise, omit completely.)
Patient goals of care:
- [Advance Care Planning Documents] (only include advance care planning documents if discussed. This will likely include advance health directives, statements of choices, acute resuscitation plans, or documents locally held in the nursing home.)
- [Trajectory of care] (include this only if there is a discussion of the intention of care, the goals and life trajectory to this point. An example may be that the focus of all care should be primarily symptom relief rather than curative intention. This is very common, and statements like “wanting to be kept comfortable” or that care should provide symptom relief should be included in this section. The goal of not going back to the hospital or reducing hospital visits in the future would be included here. The source of truth for this expressed preference should be included - did this come directly from the patient, family members, an enduring power of attorney for health matters (EPOA), or a staff member and clinician).
Management Plan:
- [describe management plan] (only include describing it if it has been explicitly mentioned in the transcript, contextual notes or clinical notes; otherwise, omit completely. The management plan will specifically be regarding the patient's disposition - this should be highlighted in bold as the first part of the management plan. It will almost always be from a selection of a few options - such as Mobile Emergency Team (MET), Geriatrician review by CAREPACT, Nurse Navigator Referral, Discharge to GP and RACF care, or Hospital Transfer. The discussion may also conclude that the patient will receive a phone call from the CAREPACT CNC to check the status of the patient - this is not for every call but will occasionally be necessary, and the medical officer will specifically mention this as the plan)
Additional Notes:
- [any additional notes] (only include any additional notes if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
