GP intervention request

Important: For nursing and 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 School Lane Surgery.

Requests must be submitted before 10am.

GP Intervention Request

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:

How long has this been a problem?

Observations:

Readings

Please provide the readings below.

Systolic “Higher”

Diastolic “Lower”

Pulse

Sats

Temperature

Blood Glucose

Respiratory Rate

Other Details

Sputum Colour:

Urinalysis:

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: