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.

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: _________________________________________________________ Address: ________________________________________________________ Phone: _________________________ Fax: ___________________________ Email: __________________________________________________________ Date of visit or phone call: __________________________________________ Care provider you spoke with: _______________________________________ Event precipitating visit or phone call, if any and/or your reason for the call: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Ask the care provider how your loved one is functioning in the following areas: Physical functioning Ambulation/falls: ________________________________________________________________________________________________________________________________

THIS

IS A

DEMO

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.

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

Medication Purpose Dosage Side effects Time of day

Diet, nutrition and eating: ________________________________________________________________________________________________________________________________ Consultations with specialist (physiotherapist, occupational therapist, social worker, etc.) ________________________________________________________________________________________________________________________________ Tests requested and purpose: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

THIS

IS A

DEMO

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.

Test results discussed: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Cognition and behavior: Mood: ________________________________________________________________________________________________________________________________ Behavior: ________________________________________________________________________________________________________________________________ Memory: ________________________________________________________________________________________________________________________________ Confusion: ________________________________________________________________________________________________________________________________ Interaction with other residents: ________________________________________________________________________________________________________________________________ Participation in activities: ________________________________________________________________________________________________________________________________ Are there any changes from my loved one’s baseline level of functioning that I should be aware of? ________________________________________________________________________________________________________________________________ Recommendations given: ________________________________________________________________________________________________________________________________________________________________________________________________

THIS

IS A

DEMO

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.

Facility follow up requested: ________________________________________________________________________________________________________________________________________________________________________________________________ Your responsibilities for follow up: ________________________________________________________________________________________________________________________________________________________________________________________________

THIS

IS A

DEMO