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CONSULTANT/SENIOR MEDICAL OFFICER SURNAME (Please print) INITIALS
SURNAME OF REQUESTING DOCTOR
FIRST NAME
AUSLAB CODE
PROVIDER NUMBER
(Please print)
Req
uest
Det
ails
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
TEST REQUESTED
WARD/ CLINICAL UNIT
LAB NO
GESTATIONAL AGE K=
DOCTORS: Please complete ALL relevant areas in the red section
CLINICAL NOTES/MEDICATIONS
URGENT n TEL n PAGE n FAX n CONTACT NO
LAB USE ONLY
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Doc
tor
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Pati
ent D
etai
ls
PATIENT SURNAME
GENDER
HOSPITAL
UR NOUR PREFIX DATE OF BIRTHMF
(Please print or place sticker on this area) PATIENT FIRST NAME
CONTACT NOPATIENT ADDRESS
D D M M Y Y YY
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Coll
ecto
r SURNAME OF COLLECTING PERSON (Please print) INITIALS
I certify that I collected the accompanying sample from the above patient whose identity was confirmed by inquiry and/or examination of their nameband and that I labelled the sample immediately following collection.
Date Time AMSignature: Collected / / Collected PM
Med
icar
e D
etai
ls
MEDICARE NUMBER
IRN
EXPHEALTH FUND NAME
VETERANS AFFAIRS
MEDICARE ASSIGNMENT FORM (Section 20A of the Health Insurance Act 1973) I offer to assign my rights to benefits to the approved pathology practitioner who will render the requested pathology service(s), and any eligible pathologist determinable service(s) established as necessary by the practitioner
Patient Signature X Date
PRACTITIONERS USE ONLY (Reason patient cannot sign)
Patient status at the time of the service or when specimen collected (please tick) Yes
n Private patient in a private hospital or approved day hospital facility nn Private patient in a recognised hospital nn Public patient in a recognised hospital nn Outpatient in a recognised hospital nn Bulk Bill Rural & Remote COAG n
PHLEBOTOMY USE ONLY
Indigenous statusAboriginal nTSI nBoth n
Non- Indigenous nNot stated n
/ /
Coll
ecti
on D
etai
ls
COLLECTION CODE CONTAINERS COLLECTED (No of Tubes)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency
at
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M
Children’s Early Warning Tool (CEWT®)
Facility:
• Full CEWT score = Respiratory rate + Respiratory distress + O2 + O
2Saturation+Temperature+
Heartrate+Bloodpressure+Capillaryrefilltime+Levelof consciousness.• AFullCEWTscoreandapainscore(p4)mustbecalculated
› on admission › once per shift (minimum 8th hourly) › if patientisdeteriorating(increasingscoreoryouareconcernedaboutthepatient).
• When graphing observations, place a dot ( )intheappropriateboxandjoin totheprecedingdot(e.g. ).Forbloodpressure,usethesymbolsindicated( ).
• Anyobservationoutsidetherangeof thegraph,youmustwritethenumber.• ScoreeachobservationbyreferringtotheCEWTScoreLegendorby
columnsoneithersideofrecordthisintheTotalCEWTscorerow,evenif thescoreiszero.
• Forabnormalobservations,youmustcontinuetocheckuntilnormal.• Asidefromtheabove,doappropriateobservationsatanappropriatefrequencyforthepatient’s
General Instructions
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:Signature:
• Modifications can ONLYbemadeonthebasisof chronicabnormalphysiology.• ModificationscanonlybeauthorisedbySMO/registrar/PHO(orequivalent).• ModificationsmustbeassessedandrewrittenwitheachnewCEWTchart.
Modifications Use if abnormal observations are tolerated for patient
Scoring Note:revert to the original score on CEWT
if O
Diagnosis which justifies modification (e.g.cysticfibrosis):
Respiratory Rate to
O2Saturation to %
O2 Flow Rate to
SystolicBP to
Heart Rate to
≥12 years and Older
For tertiary and secondary facilitiesTEST REQUESTED
WARD/CLINICAL UNIT
SURNAME OF REQUESTING OFFICER (Please print)
Requ
esti
ng O
ffice
r
CONSULTANT/SENIOR MEDICAL OFFICER SURNAME (Please print) INITIALS
SURNAME OF REQUESTING DOCTOR
FIRST NAME
AUSLAB CODE
PROVIDER NUMBER
(Please print)
Req
uest
Det
ails
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
TEST REQUESTED
WARD/ CLINICAL UNIT
LAB NO
GESTATIONAL AGE K=
DOCTORS: Please complete ALL relevant areas in the red section
CLINICAL NOTES/MEDICATIONS
URGENT n TEL n PAGE n FAX n CONTACT NO
LAB USE ONLY
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Doc
tor
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Pati
ent D
etai
ls
PATIENT SURNAME
GENDER
HOSPITAL
UR NOUR PREFIX DATE OF BIRTHMF
(Please print or place sticker on this area) PATIENT FIRST NAME
CONTACT NOPATIENT ADDRESS
D D M M Y Y YY
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Coll
ecto
r SURNAME OF COLLECTING PERSON (Please print) INITIALS
I certify that I collected the accompanying sample from the above patient whose identity was confirmed by inquiry and/or examination of their nameband and that I labelled the sample immediately following collection.
Date Time AMSignature: Collected / / Collected PM
Med
icar
e D
etai
ls
MEDICARE NUMBER
IRN
EXPHEALTH FUND NAME
VETERANS AFFAIRS
MEDICARE ASSIGNMENT FORM (Section 20A of the Health Insurance Act 1973) I offer to assign my rights to benefits to the approved pathology practitioner who will render the requested pathology service(s), and any eligible pathologist determinable service(s) established as necessary by the practitioner
Patient Signature X Date
PRACTITIONERS USE ONLY (Reason patient cannot sign)
Patient status at the time of the service or when specimen collected (please tick) Yes
n Private patient in a private hospital or approved day hospital facility nn Private patient in a recognised hospital nn Public patient in a recognised hospital nn Outpatient in a recognised hospital nn Bulk Bill Rural & Remote COAG n
PHLEBOTOMY USE ONLY
Indigenous statusAboriginal nTSI nBoth n
Non- Indigenous nNot stated n
/ /
Coll
ecti
on D
etai
ls
COLLECTION CODE CONTAINERS COLLECTED (No of Tubes)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency
at
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M
Children’s Early Warning Tool (CEWT®)
Facility:
• Full CEWT score = Respiratory rate + Respiratory distress + O2 + O
2Saturation+Temperature+
Heartrate+Bloodpressure+Capillaryrefilltime+Levelof consciousness.• AFullCEWTscoreandapainscore(p4)mustbecalculated
› on admission › once per shift (minimum 8th hourly) › if patientisdeteriorating(increasingscoreoryouareconcernedaboutthepatient).
• When graphing observations, place a dot ( )intheappropriateboxandjoin totheprecedingdot(e.g. ).Forbloodpressure,usethesymbolsindicated( ).
• Anyobservationoutsidetherangeof thegraph,youmustwritethenumber.• ScoreeachobservationbyreferringtotheCEWTScoreLegendorby
columnsoneithersideofrecordthisintheTotalCEWTscorerow,evenif thescoreiszero.
• Forabnormalobservations,youmustcontinuetocheckuntilnormal.• Asidefromtheabove,doappropriateobservationsatanappropriatefrequencyforthepatient’s
General Instructions
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:Signature:
• Modifications can ONLYbemadeonthebasisof chronicabnormalphysiology.• ModificationscanonlybeauthorisedbySMO/registrar/PHO(orequivalent).• ModificationsmustbeassessedandrewrittenwitheachnewCEWTchart.
Modifications Use if abnormal observations are tolerated for patient
Scoring Note:revert to the original score on CEWT
Example: if O2
Diagnosis which justifies modification (e.g.cysticfibrosis):
Respiratory Rate to
O2Saturation to %
O2 Flow Rate to
SystolicBP to
Heart Rate to
≥12 years and Older
For tertiary and secondary facilitiesTEST REQUESTED
WARD/CLINICAL UNIT
SURNAME OF REQUESTING OFFICER (Please print)
Requ
esti
ng O
ffice
r
V131018PU
I certify that I collected the accompanying specimen from the above patient whose identity was confirmed by enquiry and/or examination of their name band and that I labelled the specimen immediately following collection and before leaving the patient.
FIRST NAME PROVIDER NUMBER
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
URGENT n TEL n PAGE n FAX n CONTACT NO
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
VETERANS AFFAIRS
Patient Signature X
PRACTITIONERS USE ONLY (Reason patient cannot sign)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
®
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
:
Signature:
Scoring Note: observations outside the modified range revert to the original score on CEWT
Example: if O2 saturations > 90% are tolerated (score of
zero)andtheO2 saturations drop to 90%, it would score 1
NB: tick modifications box at bottom of page 3 to indicate modifications are in use
Page 4 of 4Page 1 of 4
Interventions
A
B
C
D
E
F
G
If an intervention is administered, record here and note letter in Interventions row over page in appropriate time column
Other:
Height (cm)
O2Saturation to %
O2 Flow Rate to L/min
SystolicBP to mmHg
Heart Rate to beats/min
12 YEAR
S AN
D O
LDER
TEr
TIAr
y AN
D S
EC
oN
DA
ry
•Urgentregistrarreview.opioids.ObtainafullCEWT
•ContactAcutePainServiceif pain remains severe after permitted interventions
••Obtain a full CEWT score••Serviceif
••
required
•No action
Bolus (P)aracetamol (O)pioid
Enteral (P)aracetamol (O (N)SAID (Ot
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
URGENT n TEL n PAGE n FAX n CONTACT NO
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Patient Signature X
PRACTITIONERS USE ONLY
Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
SST
CITRATE
PST
BL Culture
ABG
FL OX
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
®
Fluid Balance Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
:
Signature:
Scoring Note: observations outside the modified range revert to the original score on CEWT
Example: if O2 saturations > 90% are tolerated (score of
zero)andtheO2 saturations drop to 90%, it would score 1
NB: tick modifications box at bottom of page 3 to indicate modifications are in use
Page 4 of 4Page 1 of 4
Interventions
A
B
C
D
E
F
G
If an intervention is administered, record here and note letter in Interventions row over page in appropriate time column
Other:
Height (cm)
2
O2 Flow Rate to L/min
SystolicBP to mmHg
Heart Rate to beats/min
12 YEAR
S AN
D O
LDER
TEr
TIAr
y AN
D S
EC
oN
DA
ry
•Urgentregistrarreview.opioids.ObtainafullCEWT
•ContactAcutePainServiceif pain remains severe after permitted interventions
••Obtain a full CEWT score••Serviceif
••
required
•No action
Bolus (P)aracetamol (O)pioid
Enteral (P)aracetamol (O (N)SAID (Ot
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
V131018PU
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
ABG
OTHER
REC’D TIME INITIALS
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Page 4 of 4Page 1 of 4
G
If an
record
in
ry
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
SST
CITRATE
PST
ABG
OTHER
REC’D TIME INITIALS
Neurological Pain/Epidural/Patient Controlled AnalgesiaPage 4 of 4Page 1 of 4
If an
record
in
ry
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
V131018PU
at
CONSULTANT/SENIOR MEDICAL OFFICER SURNAME (Please print) INITIALS
SURNAME OF REQUESTING DOCTOR
FIRST NAME
AUSLAB CODE
PROVIDER NUMBER
(Please print)
Req
uest
Det
ails
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
TEST REQUESTED
WARD/ CLINICAL UNIT
LAB NO
GESTATIONAL AGE K=
DOCTORS: Please complete ALL relevant areas in the red section
CLINICAL NOTES/MEDICATIONS
URGENT n TEL n PAGE n FAX n CONTACT NO
LAB USE ONLY
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Doc
tor
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Pati
ent D
etai
ls
PATIENT SURNAME
GENDER
HOSPITAL
UR NOUR PREFIX DATE OF BIRTHMF
(Please print or place sticker on this area) PATIENT FIRST NAME
CONTACT NOPATIENT ADDRESS
D D M M Y Y YY
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Coll
ecto
r SURNAME OF COLLECTING PERSON (Please print) INITIALS
I certify that I collected the accompanying sample from the above patient whose identity was confirmed by inquiry and/or examination of their nameband and that I labelled the sample immediately following collection.
Date Time AMSignature: Collected / / Collected PM
Med
icar
e D
etai
ls
MEDICARE NUMBER
IRN
EXPHEALTH FUND NAME
VETERANS AFFAIRS
MEDICARE ASSIGNMENT FORM (Section 20A of the Health Insurance Act 1973) I offer to assign my rights to benefits to the approved pathology practitioner who will render the requested pathology service(s), and any eligible pathologist determinable service(s) established as necessary by the practitioner
Patient Signature X Date
PRACTITIONERS USE ONLY (Reason patient cannot sign)
Patient status at the time of the service or when specimen collected (please tick) Yes
n Private patient in a private hospital or approved day hospital facility nn Private patient in a recognised hospital nn Public patient in a recognised hospital nn Outpatient in a recognised hospital nn Bulk Bill Rural & Remote COAG n
PHLEBOTOMY USE ONLY
Indigenous statusAboriginal nTSI nBoth n
Non- Indigenous nNot stated n
/ /
Coll
ecti
on D
etai
ls
COLLECTION CODE CONTAINERS COLLECTED (No of Tubes)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency
at
DO
nO
t wr
ite in
this
bin
Din
g m
ar
gin
DO
nO
t w
rit
e in
th
is b
inD
ing
ma
rg
in
CE
WT
®
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M F I
Children’s Early Warning Tool (CEWT®)
Facility:
•
• •
in action box• •
infusion chart
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
• Full CEWT score = Respiratory rate + Respiratory distress + O2 + O
2Saturation+Temperature+
Heartrate+Bloodpressure+Capillaryrefilltime+Levelof consciousness.• AFullCEWTscoreandapainscore(p4)mustbecalculated
› on admission › once per shift (minimum 8th hourly) › if patientisdeteriorating(increasingscoreoryouareconcernedaboutthepatient).
• When graphing observations, place a dot ( )intheappropriateboxandjoin totheprecedingdot(e.g. ).Forbloodpressure,usethesymbolsindicated( ).
• Anyobservationoutsidetherangeof thegraph,youmustwritethenumber.• ScoreeachobservationbyreferringtotheCEWTScoreLegendorbyaligningthedotwiththescoring
columnsoneithersideof thegraph.AddupallobservationscorestocalculatetheTotalCEWTscoreandrecordthisintheTotalCEWTscorerow,evenif thescoreiszero.
• Forabnormalobservations,youmustcontinuetocheckuntilnormal.• Asidefromtheabove,doappropriateobservationsatanappropriatefrequencyforthepatient’sclinicalstatus.
General Instructions
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
:
Signature:
• Modifications can ONLYbemadeonthebasisof chronicabnormalphysiology.• ModificationscanonlybeauthorisedbySMO/registrar/PHO(orequivalent).• ModificationsmustbeassessedandrewrittenwitheachnewCEWTchart.
Modifications Use if abnormal observations are tolerated for patient
Scoring Note: observations outside the modified range revert to the original score on CEWT
Example: if O2 saturations > 90% are tolerated (score of
zero)andtheO2 saturations drop to 90%, it would score 1
NB: tick modifications box at bottom of page 3 to indicate modifications are in use
Write the acceptable range (will score zero) below:Diagnosis which justifies modification (e.g.cysticfibrosis):
Page 4 of 4Page 1 of 4
Interventions
A
B
C
D
E
F
G
If an intervention is administered, record here and note letter in Interventions row over page in appropriate time column
Additional ObservationsDate
Time
Weight (kg)
Other:
Height (cm)
Respiratory Rate to breaths/min
O2Saturation to %
O2 Flow Rate to L/min
SystolicBP to mmHg
Heart Rate to beats/min
12 YEAR
S AN
D O
LDER
≥ 12 years12 years and Older
References: FPS-R:HicksCLetal.,PAIN2001;93:173.©2001InternationalAssociationfortheStudyof Pain,reproducedwithpermission.www.iasp-pain.org/FPSR
NumericalSuggested age: 7+ years
Askchildtotelltheirlevelof pain from scale
The Faces Pain Scale – Revised (FPS-R)
Suggested age: 3+ years (or if unable to use numerical)
“Thesefacesshowhowmuchsomethingcanhurt.Thisface[pointtoleft-mostface]showsnopain.Thefacesshowmoreandmorepain[pointtoeachfromlefttoright]uptothisone[pointtoright-mostface]–itshowsverymuchpain.Pointtothefacethatshowshowmuchyouhurt[rightnow].”
0 2 4 6 8 10
For tertiary and secondary facilities
TEr
TIAr
y AN
D S
EC
oN
DA
ry
Pain Assessment Chart Date
Time Actions: Pain Score
•Urgentregistrarreview.Consideropioids.ObtainafullCEWTscore.
•ContactAcutePainServiceif pain remains severe after permitted interventions
10
9
8
•Administerprescribedanalgesia•Obtain a full CEWT score•Registrar review if no improvement•ConsiderreferraltoAcutePainServiceif interventionsineffective
7
6
5
4
•Administerprescribedanalgesia•Ward doctor review to prescribe if
required
3
2
1
•No action 0
Bolus Indicate if IV bolus given(P)aracetamol (O)pioid (Ot)her
Enteral (P)aracetamol (O)pioid (N)SAID (Ot)her
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
TEST REQUESTED
WARD/CLINICAL UNIT
SURNAME OF REQUESTING OFFICER (Please print)
Requ
esti
ng O
ffice
r
CONSULTANT/SENIOR MEDICAL OFFICER SURNAME (Please print) INITIALS
SURNAME OF REQUESTING DOCTOR
FIRST NAME
AUSLAB CODE
PROVIDER NUMBER
(Please print)
Req
uest
Det
ails
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
TEST REQUESTED
WARD/ CLINICAL UNIT
LAB NO
GESTATIONAL AGE K=
DOCTORS: Please complete ALL relevant areas in the red section
CLINICAL NOTES/MEDICATIONS
URGENT n TEL n PAGE n FAX n CONTACT NO
LAB USE ONLY
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Doc
tor
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Pati
ent D
etai
ls
PATIENT SURNAME
GENDER
HOSPITAL
UR NOUR PREFIX DATE OF BIRTHMF
(Please print or place sticker on this area) PATIENT FIRST NAME
CONTACT NOPATIENT ADDRESS
D D M M Y Y YY
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Coll
ecto
r SURNAME OF COLLECTING PERSON (Please print) INITIALS
I certify that I collected the accompanying sample from the above patient whose identity was confirmed by inquiry and/or examination of their nameband and that I labelled the sample immediately following collection.
Date Time AMSignature: Collected / / Collected PM
Med
icar
e D
etai
ls
MEDICARE NUMBER
IRN
EXPHEALTH FUND NAME
VETERANS AFFAIRS
MEDICARE ASSIGNMENT FORM (Section 20A of the Health Insurance Act 1973) I offer to assign my rights to benefits to the approved pathology practitioner who will render the requested pathology service(s), and any eligible pathologist determinable service(s) established as necessary by the practitioner
Patient Signature X Date
PRACTITIONERS USE ONLY (Reason patient cannot sign)
Patient status at the time of the service or when specimen collected (please tick) Yes
n Private patient in a private hospital or approved day hospital facility nn Private patient in a recognised hospital nn Public patient in a recognised hospital nn Outpatient in a recognised hospital nn Bulk Bill Rural & Remote COAG n
PHLEBOTOMY USE ONLY
Indigenous statusAboriginal nTSI nBoth n
Non- Indigenous nNot stated n
/ /
Coll
ecti
on D
etai
ls
COLLECTION CODE CONTAINERS COLLECTED (No of Tubes)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency
at
DO
nO
t wr
ite in
this
bin
Din
g m
ar
gin
DO
nO
t w
rit
e in
th
is b
inD
ing
ma
rg
in
CE
WT
®
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M F I
Children’s Early Warning Tool (CEWT®)
Facility:
•
• •
in action box• •
infusion chart
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
• Full CEWT score = Respiratory rate + Respiratory distress + O2 + O
2Saturation+Temperature+
Heartrate+Bloodpressure+Capillaryrefilltime+Levelof consciousness.• AFullCEWTscoreandapainscore(p4)mustbecalculated
› on admission › once per shift (minimum 8th hourly) › if patientisdeteriorating(increasingscoreoryouareconcernedaboutthepatient).
• When graphing observations, place a dot ( )intheappropriateboxandjoin totheprecedingdot(e.g. ).Forbloodpressure,usethesymbolsindicated( ).
• Anyobservationoutsidetherangeof thegraph,youmustwritethenumber.• ScoreeachobservationbyreferringtotheCEWTScoreLegendorbyaligningthedotwiththescoring
columnsoneithersideof thegraph.AddupallobservationscorestocalculatetheTotalCEWTscoreandrecordthisintheTotalCEWTscorerow,evenif thescoreiszero.
• Forabnormalobservations,youmustcontinuetocheckuntilnormal.• Asidefromtheabove,doappropriateobservationsatanappropriatefrequencyforthepatient’sclinicalstatus.
General Instructions
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
:
Signature:
• Modifications can ONLYbemadeonthebasisof chronicabnormalphysiology.• ModificationscanonlybeauthorisedbySMO/registrar/PHO(orequivalent).• ModificationsmustbeassessedandrewrittenwitheachnewCEWTchart.
Modifications Use if abnormal observations are tolerated for patient
Scoring Note: observations outside the modified range revert to the original score on CEWT
Example: if O2 saturations > 90% are tolerated (score of
zero)andtheO2 saturations drop to 90%, it would score 1
NB: tick modifications box at bottom of page 3 to indicate modifications are in use
Write the acceptable range (will score zero) below:Diagnosis which justifies modification (e.g.cysticfibrosis):
Page 4 of 4Page 1 of 4
Interventions
A
B
C
D
E
F
G
If an intervention is administered, record here and note letter in Interventions row over page in appropriate time column
Additional ObservationsDate
Time
Weight (kg)
Other:
Height (cm)
Respiratory Rate to breaths/min
O2Saturation to %
O2 Flow Rate to L/min
SystolicBP to mmHg
Heart Rate to beats/min
12 YEAR
S AN
D O
LDER
≥ 12 years12 years and Older
References: FPS-R:HicksCLetal.,PAIN2001;93:173.©2001InternationalAssociationfortheStudyof Pain,reproducedwithpermission.www.iasp-pain.org/FPSR
NumericalSuggested age: 7+ years
Askchildtotelltheirlevelof pain from scale
The Faces Pain Scale – Revised (FPS-R)
Suggested age: 3+ years (or if unable to use numerical)
“Thesefacesshowhowmuchsomethingcanhurt.Thisface[pointtoleft-mostface]showsnopain.Thefacesshowmoreandmorepain[pointtoeachfromlefttoright]uptothisone[pointtoright-mostface]–itshowsverymuchpain.Pointtothefacethatshowshowmuchyouhurt[rightnow].”
0 2 4 6 8 10
For tertiary and secondary facilities
TEr
TIAr
y AN
D S
EC
oN
DA
ry
Pain Assessment Chart Date
Time Actions: Pain Score
•Urgentregistrarreview.Consideropioids.ObtainafullCEWTscore.
•ContactAcutePainServiceif pain remains severe after permitted interventions
10
9
8
•Administerprescribedanalgesia•Obtain a full CEWT score•Registrar review if no improvement•ConsiderreferraltoAcutePainServiceif interventionsineffective
7
6
5
4
•Administerprescribedanalgesia•Ward doctor review to prescribe if
required
3
2
1
•No action 0
Bolus Indicate if IV bolus given(P)aracetamol (O)pioid (Ot)her
Enteral (P)aracetamol (O)pioid (N)SAID (Ot)her
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
TEST REQUESTED
WARD/CLINICAL UNIT
SURNAME OF REQUESTING OFFICER (Please print)
Requ
esti
ng O
ffice
r
V131018PU
I certify that I collected the accompanying specimen from the above patient whose identity was confirmed by enquiry and/or examination of their name band and that I labelled the specimen immediately following collection and before leaving the patient.
at
CONSULTANT/SENIOR MEDICAL OFFICER SURNAME (Please print) INITIALS
SURNAME OF REQUESTING DOCTOR
FIRST NAME
AUSLAB CODE
PROVIDER NUMBER
(Please print)
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
GESTATIONAL AGE K=CLINICAL NOTES/MEDICATIONS
URGENT n TEL n PAGE n FAX n CONTACT NO
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Doc
tor
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Pati
ent D
etai
ls
PATIENT SURNAME
GENDER
HOSPITAL
UR NOUR PREFIXMF
(Please print or place sticker on this area)
PATIENT ADDRESS
D
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Coll
ecto
r SURNAME OF COLLECTING PERSON (Please print) INITIALS
I certify that I collected the accompanying sample from the above patient whose identity was confirmed by inquiry and/or examination of their nameband and that I labelled the sample immediately following collection.
Date Time AMSignature: Collected / / Collected PM
Med
icar
e D
etai
ls
MEDICARE NUMBER
IRN
EXPHEALTH FUND NAME
VETERANS AFFAIRS
MEDICARE ASSIGNMENT FORM (Section 20A of the Health Insurance Act 1973) I offer to assign my rights to benefits to the approved pathology practitioner who will render the requested pathology service(s), and any eligible pathologist determinable service(s) established as necessary by the practitioner
Patient Signature X Date
PRACTITIONERS USE ONLY (Reason patient cannot sign)
n Private patient in a private hospital or approved day hospital facility n Private patient in a recognised hospital n Public patient in a recognised hospital n Outpatient in a recognised hospital n Bulk Bill Rural & Remote COAG
Indigenous statusAboriginal nTSI nBoth n
Non- Indigenous nNot stated n
/ /
Coll
ecti
on D
etai
ls
COLLECTION CODE CONTAINERS COLLECTED (No of Tubes)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency
at
DO
nO
t wr
ite in
this
bin
Din
g m
ar
gin
DO
nO
t w
rit
e in
th
is b
inD
ing
ma
rg
in
CE
WT
®
Facility:
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
•
• › › › if
• When graphing observations, place a dot ( )intheappropriateboxandjoin totheprecedingdot(e.g. ).Forbloodpressure,usethesymbolsindicated( ).
• Anyobservationoutsidetherangeof thegraph,youmustwritethenumber.• ScoreeachobservationbyreferringtotheCEWTScoreLegendorbyaligningthedotwiththescoring
columnsoneithersideof thegraph.AddupallobservationscorestocalculatetheTotalCEWTscoreandrecordthisintheTotalCEWTscorerow,evenif thescoreiszero.
• Forabnormalobservations,youmustcontinuetocheckuntilnormal.• Asidefromtheabove,doappropriateobservationsatanappropriatefrequencyforthepatient’sclinicalstatus.
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
:
Signature:
• Modifications can ONLYbemadeonthebasisof chronicabnormalphysiology.• ModificationscanonlybeauthorisedbySMO/registrar/PHO(orequivalent).• ModificationsmustbeassessedandrewrittenwitheachnewCEWTchart.
Modifications Use if abnormal observations are tolerated for patient
Scoring Note: observations outside the modified range revert to the original score on CEWT
Example: if O2 saturations > 90% are tolerated (score of
zero)andtheO2 saturations drop to 90%, it would score 1
NB: tick modifications box at bottom of page 3 to indicate modifications are in use
Write the acceptable range (will score zero) below:Diagnosis which justifies modification (e.g.cysticfibrosis):
Page 4 of 4Page 1 of 4
Interventions
A
B
C
D
E
F
G
If an intervention is administered, record here and note letter in Interventions row over page in appropriate time column
Additional ObservationsDate
Time
Weight (kg)
Other:
Height (cm)
Respiratory Rate to breaths/min
O2Saturation to %
O2 Flow Rate to L/min
SystolicBP to mmHg
Heart Rate to beats/min
12 YEAR
S AN
D O
LDER
References: FPS-R:HicksCLetal.,PAIN2001;93:173.©2001InternationalAssociationfortheStudyof Pain,reproducedwithpermission.www.iasp-pain.org/FPSR
8 9 10Worst Pain
The Faces Pain Scale – Revised (FPS-R)
Suggested age: 3+ years (or if unable to use numerical)
“Thesefacesshowhowmuchsomethingcanhurt.Thisface[pointtoleft-mostface]showsnopain.Thefacesshowmoreandmorepain[pointtoeachfromlefttoright]uptothisone[pointtoright-mostface]–itshowsverymuchpain.Pointtothefacethatshowshowmuchyouhurt[rightnow].”
0 2 4 6 8 10
TEr
TIAr
y AN
D S
EC
oN
DA
ry
Pain Assessment Chart Date
Time Actions: Pain Score
•Urgentregistrarreview.Consideropioids.ObtainafullCEWTscore.
•ContactAcutePainServiceif pain remains severe after permitted interventions
10
9
8
•Administerprescribedanalgesia•Obtain a full CEWT score•Registrar review if no improvement•ConsiderreferraltoAcutePainServiceif interventionsineffective
7
6
5
4
•Administerprescribedanalgesia•Ward doctor review to prescribe if
required
3
2
1
•No action 0
Bolus Indicate if IV bolus given(P)aracetamol (O)pioid (Ot)her
Enteral (P)aracetamol (O)pioid (N)SAID (Ot)her
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
SURNAME OF REQUESTING OFFICER (Please print)
Requ
esti
ng O
ffice
r
CONSULTANT/SENIOR MEDICAL OFFICER SURNAME (Please print) INITIALS
SURNAME OF REQUESTING DOCTOR
FIRST NAME
AUSLAB CODE
PROVIDER NUMBER
(Please print)
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
GESTATIONAL AGE K=CLINICAL NOTES/MEDICATIONS
URGENT n TEL n PAGE n FAX n CONTACT NO
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Doc
tor
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Pati
ent D
etai
ls
PATIENT SURNAME
GENDER
HOSPITAL
UR NOUR PREFIXMF
(Please print or place sticker on this area)
PATIENT ADDRESS
D
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Coll
ecto
r SURNAME OF COLLECTING PERSON (Please print) INITIALS
I certify that I collected the accompanying sample from the above patient whose identity was confirmed by inquiry and/or examination of their nameband and that I labelled the sample immediately following collection.
Date Time AMSignature: Collected / / Collected PM
Med
icar
e D
etai
ls
MEDICARE NUMBER
IRN
EXPHEALTH FUND NAME
VETERANS AFFAIRS
MEDICARE ASSIGNMENT FORM (Section 20A of the Health Insurance Act 1973) I offer to assign my rights to benefits to the approved pathology practitioner who will render the requested pathology service(s), and any eligible pathologist determinable service(s) established as necessary by the practitioner
Patient Signature X Date
PRACTITIONERS USE ONLY (Reason patient cannot sign)
n Private patient in a private hospital or approved day hospital facility n Private patient in a recognised hospital n Public patient in a recognised hospital n Outpatient in a recognised hospital n Bulk Bill Rural & Remote COAG
Indigenous statusAboriginal nTSI nBoth n
Non- Indigenous nNot stated n
/ /
Coll
ecti
on D
etai
ls
COLLECTION CODE CONTAINERS COLLECTED (No of Tubes)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency
at
DO
nO
t wr
ite in
this
bin
Din
g m
ar
gin
DO
nO
t w
rit
e in
th
is b
inD
ing
ma
rg
in
CE
WT
®
Facility:
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
•
• › › › if
• totheprecedingdot(e.g. ).Forbloodpressure,usethesymbolsindicated( ).
• Anyobservationoutsidetherangeof thegraph,youmustwritethenumber.• ScoreeachobservationbyreferringtotheCEWTScoreLegendorbyaligningthedotwiththescoring
columnsoneithersideof thegraph.AddupallobservationscorestocalculatetheTotalCEWTscoreandrecordthisintheTotalCEWTscorerow,evenif thescoreiszero.
• Forabnormalobservations,youmustcontinuetocheckuntilnormal.• Asidefromtheabove,doappropriateobservationsatanappropriatefrequencyforthepatient’sclinicalstatus.
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
:
Signature:
• Modifications can ONLYbemadeonthebasisof chronicabnormalphysiology.• ModificationscanonlybeauthorisedbySMO/registrar/PHO(orequivalent).• ModificationsmustbeassessedandrewrittenwitheachnewCEWTchart.
Modifications Use if abnormal observations are tolerated for patient
Scoring Note: observations outside the modified range revert to the original score on CEWT
Example: if O2 saturations > 90% are tolerated (score of
zero)andtheO2 saturations drop to 90%, it would score 1
NB: tick modifications box at bottom of page 3 to indicate modifications are in use
Write the acceptable range (will score zero) below:Diagnosis which justifies modification (e.g.cysticfibrosis):
Page 4 of 4Page 1 of 4
Interventions
A
B
C
D
E
F
G
If an intervention is administered, record here and note letter in Interventions row over page in appropriate time column
Additional ObservationsDate
Time
Weight (kg)
Other:
Height (cm)
Respiratory Rate to breaths/min
O2Saturation to %
O2 Flow Rate to L/min
SystolicBP to mmHg
Heart Rate to beats/min
12 YEAR
S AN
D O
LDER
References: FPS-R:HicksCLetal.,PAIN2001;93:173.©2001InternationalAssociationfortheStudyof Pain,reproducedwithpermission.www.iasp-pain.org/FPSR
8 9 10Worst Pain
The Faces Pain Scale – Revised (FPS-R)
Suggested age: 3+ years (or if unable to use numerical)
“Thesefacesshowhowmuchsomethingcanhurt.Thisface[pointtoleft-mostface]showsnopain.Thefacesshowmoreandmorepain[pointtoeachfromlefttoright]uptothisone[pointtoright-mostface]–itshowsverymuchpain.Pointtothefacethatshowshowmuchyouhurt[rightnow].”
0 2 4 6 8 10
TEr
TIAr
y AN
D S
EC
oN
DA
ry
Pain Assessment Chart Date
Time Actions: Pain Score
•Urgentregistrarreview.Consideropioids.ObtainafullCEWTscore.
•ContactAcutePainServiceif pain remains severe after permitted interventions
10
9
8
•Administerprescribedanalgesia•Obtain a full CEWT score•Registrar review if no improvement•ConsiderreferraltoAcutePainServiceif interventionsineffective
7
6
5
4
•Administerprescribedanalgesia•Ward doctor review to prescribe if
required
3
2
1
•No action 0
Bolus Indicate if IV bolus given(P)aracetamol (O)pioid (Ot)her
Enteral (P)aracetamol (O)pioid (N)SAID (Ot)her
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
SURNAME OF REQUESTING OFFICER (Please print)
Requ
esti
ng O
ffice
r
V131018PU
I certify that I collected the accompanying specimen from the above patient whose identity was confirmed by enquiry and/or examination of their name band and that I labelled the specimen immediately following collection and before leaving the patient.
at
CONSULTANT/SENIOR MEDICAL OFFICER SURNAME (Please print) INITIALS
SURNAME OF REQUESTING DOCTOR
FIRST NAME
AUSLAB CODE
PROVIDER NUMBER
(Please print)
Req
uest
Det
ails
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
TEST REQUESTED
WARD/ CLINICAL UNIT
LAB NO
GESTATIONAL AGE K=
DOCTORS: Please complete ALL relevant areas in the red section
CLINICAL NOTES/MEDICATIONS
URGENT n TEL n PAGE n FAX n CONTACT NO
LAB USE ONLY
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Doc
tor
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Pati
ent D
etai
ls
PATIENT SURNAME
GENDER
HOSPITAL
UR NOUR PREFIX DATE OF BIRTHMF
(Please print or place sticker on this area) PATIENT FIRST NAME
CONTACT NOPATIENT ADDRESS
D D M M Y Y YY
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Coll
ecto
r SURNAME OF COLLECTING PERSON (Please print) INITIALS
I certify that I collected the accompanying sample from the above patient whose identity was confirmed by inquiry and/or examination of their nameband and that I labelled the sample immediately following collection.
Date Time AMSignature: Collected / / Collected PM
Med
icar
e D
etai
ls
MEDICARE NUMBER
IRN
EXPHEALTH FUND NAME
VETERANS AFFAIRS
MEDICARE ASSIGNMENT FORM (Section 20A of the Health Insurance Act 1973) I offer to assign my rights to benefits to the approved pathology practitioner who will render the requested pathology service(s), and any eligible pathologist determinable service(s) established as necessary by the practitioner
Patient Signature X Date
PRACTITIONERS USE ONLY (Reason patient cannot sign)
Patient status at the time of the service or when specimen collected (please tick) Yes
n Private patient in a private hospital or approved day hospital facility nn Private patient in a recognised hospital nn Public patient in a recognised hospital nn Outpatient in a recognised hospital nn Bulk Bill Rural & Remote COAG n
PHLEBOTOMY USE ONLY
Indigenous statusAboriginal nTSI nBoth n
Non- Indigenous nNot stated n
/ /
Coll
ecti
on D
etai
ls
COLLECTION CODE CONTAINERS COLLECTED (No of Tubes)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency
at
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M
Children’s Early Warning Tool (CEWT®)
Facility:
• Full CEWT score = Respiratory rate + Respiratory distress + O2 + O
2Saturation+Temperature+
Heartrate+Bloodpressure+Capillaryrefilltime+Levelof consciousness.• AFullCEWTscoreandapainscore(p4)mustbecalculated
› on admission › once per shift (minimum 8th hourly) › if patientisdeteriorating(increasingscoreoryouareconcernedaboutthepatient).
• When graphing observations, place a dot ( )intheappropriateboxandjoin totheprecedingdot(e.g. ).Forbloodpressure,usethesymbolsindicated( ).
• Anyobservationoutsidetherangeof thegraph,youmustwritethenumber.• ScoreeachobservationbyreferringtotheCEWTScoreLegendorby
columnsoneithersideofrecordthisintheTotalCEWTscorerow,evenif thescoreiszero.
• Forabnormalobservations,youmustcontinuetocheckuntilnormal.• Asidefromtheabove,doappropriateobservationsatanappropriatefrequencyforthepatient’s
General Instructions
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:
Signature:
• Modifications can ONLYbemadeonthebasisof chronicabnormalphysiology.• ModificationscanonlybeauthorisedbySMO/registrar/PHO(orequivalent).• ModificationsmustbeassessedandrewrittenwitheachnewCEWTchart.
Modifications Use if abnormal observations are tolerated for patient
Scoring Note:revert to the original score on CEWT
if O
Diagnosis which justifies modification (e.g.cysticfibrosis):
Respiratory Rate to
O2Saturation to %
O2 Flow Rate to
SystolicBP to
Heart Rate to
≥12 years and Older
For tertiary and secondary facilitiesTEST REQUESTED
WARD/CLINICAL UNIT
SURNAME OF REQUESTING OFFICER (Please print)
Requ
esti
ng O
ffice
r
CONSULTANT/SENIOR MEDICAL OFFICER SURNAME (Please print) INITIALS
SURNAME OF REQUESTING DOCTOR
FIRST NAME
AUSLAB CODE
PROVIDER NUMBER
(Please print)
Req
uest
Det
ails
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
TEST REQUESTED
WARD/ CLINICAL UNIT
LAB NO
GESTATIONAL AGE K=
DOCTORS: Please complete ALL relevant areas in the red section
CLINICAL NOTES/MEDICATIONS
URGENT n TEL n PAGE n FAX n CONTACT NO
LAB USE ONLY
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Doc
tor
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Pati
ent D
etai
ls
PATIENT SURNAME
GENDER
HOSPITAL
UR NOUR PREFIX DATE OF BIRTHMF
(Please print or place sticker on this area) PATIENT FIRST NAME
CONTACT NOPATIENT ADDRESS
D D M M Y Y YY
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Coll
ecto
r SURNAME OF COLLECTING PERSON (Please print) INITIALS
I certify that I collected the accompanying sample from the above patient whose identity was confirmed by inquiry and/or examination of their nameband and that I labelled the sample immediately following collection.
Date Time AMSignature: Collected / / Collected PM
Med
icar
e D
etai
ls
MEDICARE NUMBER
IRN
EXPHEALTH FUND NAME
VETERANS AFFAIRS
MEDICARE ASSIGNMENT FORM (Section 20A of the Health Insurance Act 1973) I offer to assign my rights to benefits to the approved pathology practitioner who will render the requested pathology service(s), and any eligible pathologist determinable service(s) established as necessary by the practitioner
Patient Signature X Date
PRACTITIONERS USE ONLY (Reason patient cannot sign)
Patient status at the time of the service or when specimen collected (please tick) Yes
n Private patient in a private hospital or approved day hospital facility nn Private patient in a recognised hospital nn Public patient in a recognised hospital nn Outpatient in a recognised hospital nn Bulk Bill Rural & Remote COAG n
PHLEBOTOMY USE ONLY
Indigenous statusAboriginal nTSI nBoth n
Non- Indigenous nNot stated n
/ /
Coll
ecti
on D
etai
ls
COLLECTION CODE CONTAINERS COLLECTED (No of Tubes)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency
at
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M
Children’s Early Warning Tool (CEWT®)
Facility:
• Full CEWT score = Respiratory rate + Respiratory distress + O2 + O
2Saturation+Temperature+
Heartrate+Bloodpressure+Capillaryrefilltime+Levelof consciousness.• AFullCEWTscoreandapainscore(p4)mustbecalculated
› on admission › once per shift (minimum 8th hourly) › if patientisdeteriorating(increasingscoreoryouareconcernedaboutthepatient).
• When graphing observations, place a dot ( )intheappropriateboxandjoin totheprecedingdot(e.g. ).Forbloodpressure,usethesymbolsindicated( ).
• Anyobservationoutsidetherangeof thegraph,youmustwritethenumber.• ScoreeachobservationbyreferringtotheCEWTScoreLegendorby
columnsoneithersideofrecordthisintheTotalCEWTscorerow,evenif thescoreiszero.
• Forabnormalobservations,youmustcontinuetocheckuntilnormal.• Asidefromtheabove,doappropriateobservationsatanappropriatefrequencyforthepatient’s
General Instructions
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
Signature:
• Modifications can ONLYbemadeonthebasisof chronicabnormalphysiology.• ModificationscanonlybeauthorisedbySMO/registrar/PHO(orequivalent).• ModificationsmustbeassessedandrewrittenwitheachnewCEWTchart.
Modifications Use if abnormal observations are tolerated for patient
Scoring Note:revert to the original score on CEWT
Example: if O2
Diagnosis which justifies modification (e.g.cysticfibrosis):
Respiratory Rate to
O2Saturation to %
O2 Flow Rate to
SystolicBP to
Heart Rate to
≥12 years and Older
For tertiary and secondary facilitiesTEST REQUESTED
WARD/CLINICAL UNIT
SURNAME OF REQUESTING OFFICER (Please print)
Requ
esti
ng O
ffice
r
V131018PU
I certify that I collected the accompanying specimen from the above patient whose identity was confirmed by enquiry and/or examination of their name band and that I labelled the specimen immediately following collection and before leaving the patient.
FIRST NAME PROVIDER NUMBER
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
URGENT n TEL n PAGE n FAX n CONTACT NO
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
VETERANS AFFAIRS
Patient Signature X
PRACTITIONERS USE ONLY (Reason patient cannot sign)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
SST
CITRATE
PST
BL Culture
ABG
FL OX
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
®
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
:
Signature:
Scoring Note: observations outside the modified range revert to the original score on CEWT
Example: if O2 saturations > 90% are tolerated (score of
zero)andtheO2 saturations drop to 90%, it would score 1
NB: tick modifications box at bottom of page 3 to indicate modifications are in use
Page 4 of 4Page 1 of 4
Interventions
A
B
C
D
E
F
G
If an intervention is administered, record here and note letter in Interventions row over page in appropriate time column
Other:
Height (cm)
O2Saturation to %
O2 Flow Rate to L/min
SystolicBP to mmHg
Heart Rate to beats/min
12 YEAR
S AN
D O
LDER
TEr
TIAr
y AN
D S
EC
oN
DA
ry
•Urgentregistrarreview.opioids.ObtainafullCEWT
•
permitted interventions
••Obtain a full CEWT score••Serviceif
••
required
•No action
Bolus (P)aracetamol (O)pioid
Enteral (P)aracetamol (O (N)SAID (Ot
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
URGENT n TEL n PAGE n FAX n CONTACT NO
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Patient Signature X
PRACTITIONERS USE ONLY
Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
SST
CITRATE
PST
BL Culture
ABG
FL OX
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
®
Fluid Balance Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
:
Signature:
Scoring Note: observations outside the modified range revert to the original score on CEWT
Example: if O2 saturations > 90% are tolerated (score of
zero)andtheO2 saturations drop to 90%, it would score 1
NB: tick modifications box at bottom of page 3 to indicate modifications are in use
Page 4 of 4Page 1 of 4
Interventions
A
B
C
D
E
F
G
If an intervention is administered, record here and note letter in Interventions row over page in appropriate time column
Other:
Height (cm)
2
O2 Flow Rate to L/min
SystolicBP to mmHg
Heart Rate to beats/min
12 YEAR
S AN
D O
LDER
TEr
TIAr
y AN
D S
EC
oN
DA
ry
•Urgentregistrarreview.opioids.ObtainafullCEWT
•
permitted interventions
••Obtain a full CEWT score••Serviceif
••
required
•No action
Bolus (P)aracetamol (O)pioid
Enteral (P)aracetamol (O (N)SAID (Ot
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
V131018PU
at
CONSULTANT/SENIOR MEDICAL OFFICER SURNAME (Please print) INITIALS
SURNAME OF REQUESTING DOCTOR
FIRST NAME
AUSLAB CODE
PROVIDER NUMBER
(Please print)
Req
uest
Det
ails
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
TEST REQUESTED
WARD/ CLINICAL UNIT
LAB NO
GESTATIONAL AGE K=
DOCTORS: Please complete ALL relevant areas in the red section
CLINICAL NOTES/MEDICATIONS
URGENT n TEL n PAGE n FAX n CONTACT NO
LAB USE ONLY
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Doc
tor
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Pati
ent D
etai
ls
PATIENT SURNAME
GENDER
HOSPITAL
UR NOUR PREFIX DATE OF BIRTHMF
(Please print or place sticker on this area) PATIENT FIRST NAME
CONTACT NOPATIENT ADDRESS
D D M M Y Y YY
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Coll
ecto
r SURNAME OF COLLECTING PERSON (Please print) INITIALS
I certify that I collected the accompanying sample from the above patient whose identity was confirmed by inquiry and/or examination of their nameband and that I labelled the sample immediately following collection.
Date Time AMSignature: Collected / / Collected PM
Med
icar
e D
etai
ls
MEDICARE NUMBER
IRN
EXPHEALTH FUND NAME
VETERANS AFFAIRS
MEDICARE ASSIGNMENT FORM (Section 20A of the Health Insurance Act 1973) I offer to assign my rights to benefits to the approved pathology practitioner who will render the requested pathology service(s), and any eligible pathologist determinable service(s) established as necessary by the practitioner
Patient Signature X Date
PRACTITIONERS USE ONLY (Reason patient cannot sign)
Patient status at the time of the service or when specimen collected (please tick) Yes
n Private patient in a private hospital or approved day hospital facility nn Private patient in a recognised hospital nn Public patient in a recognised hospital nn Outpatient in a recognised hospital nn Bulk Bill Rural & Remote COAG n
PHLEBOTOMY USE ONLY
Indigenous statusAboriginal nTSI nBoth n
Non- Indigenous nNot stated n
/ /
Coll
ecti
on D
etai
ls
COLLECTION CODE CONTAINERS COLLECTED (No of Tubes)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency
at
DO
nO
t wr
ite in
this
bin
Din
g m
ar
gin
DO
nO
t w
rit
e in
th
is b
inD
ing
ma
rg
in
CE
WT
®
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M F I
Children’s Early Warning Tool (CEWT®)
Facility:
•
• •
in action box• •
infusion chart
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
• Full CEWT score = Respiratory rate + Respiratory distress + O2 + O
2Saturation+Temperature+
Heartrate+Bloodpressure+Capillaryrefilltime+Levelof consciousness.• AFullCEWTscoreandapainscore(p4)mustbecalculated
› on admission › once per shift (minimum 8th hourly) › if patientisdeteriorating(increasingscoreoryouareconcernedaboutthepatient).
• When graphing observations, place a dot ( )intheappropriateboxandjoin totheprecedingdot(e.g. ).Forbloodpressure,usethesymbolsindicated( ).
• Anyobservationoutsidetherangeof thegraph,youmustwritethenumber.• ScoreeachobservationbyreferringtotheCEWTScoreLegendorbyaligningthedotwiththescoring
columnsoneithersideof thegraph.AddupallobservationscorestocalculatetheTotalCEWTscoreandrecordthisintheTotalCEWTscorerow,evenif thescoreiszero.
• Forabnormalobservations,youmustcontinuetocheckuntilnormal.• Asidefromtheabove,doappropriateobservationsatanappropriatefrequencyforthepatient’sclinicalstatus.
General Instructions
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
:
Signature:
• Modifications can ONLYbemadeonthebasisof chronicabnormalphysiology.• ModificationscanonlybeauthorisedbySMO/registrar/PHO(orequivalent).• ModificationsmustbeassessedandrewrittenwitheachnewCEWTchart.
Modifications Use if abnormal observations are tolerated for patient
Scoring Note: observations outside the modified range revert to the original score on CEWT
Example: if O2 saturations > 90% are tolerated (score of
zero)andtheO2 saturations drop to 90%, it would score 1
NB: tick modifications box at bottom of page 3 to indicate modifications are in use
Write the acceptable range (will score zero) below:Diagnosis which justifies modification (e.g.cysticfibrosis):
Page 4 of 4Page 1 of 4
Interventions
A
B
C
D
E
F
G
If an intervention is administered, record here and note letter in Interventions row over page in appropriate time column
Additional ObservationsDate
Time
Weight (kg)
Other:
Height (cm)
Respiratory Rate to breaths/min
O2Saturation to %
O2 Flow Rate to L/min
SystolicBP to mmHg
Heart Rate to beats/min
12 YEAR
S AN
D O
LDER
≥ 12 years12 years and Older
References: FPS-R:HicksCLetal.,PAIN2001;93:173.©2001InternationalAssociationfortheStudyof Pain,reproducedwithpermission.www.iasp-pain.org/FPSR
Numerical
Askchildtotelltheirlevelof pain from scale
The Faces Pain Scale – Revised (FPS-R)
Suggested age: 3+ years (or if unable to use numerical)
“Thesefacesshowhowmuchsomethingcanhurt.Thisface[pointtoleft-mostface]showsnopain.Thefacesshowmoreandmorepain[pointtoeachfromlefttoright]uptothisone[pointtoright-mostface]–itshowsverymuchpain.Pointtothefacethatshowshowmuchyouhurt[rightnow].”
0 2 4 6 8 10
For tertiary and secondary facilities
TEr
TIAr
y AN
D S
EC
oN
DA
ry
Pain Assessment Chart Date
Time Actions: Pain Score
•Urgentregistrarreview.Consideropioids.ObtainafullCEWTscore.
•ContactAcutePainServiceif pain remains severe after permitted interventions
10
9
8
•Administerprescribedanalgesia•Obtain a full CEWT score•Registrar review if no improvement•ConsiderreferraltoAcutePainServiceif interventionsineffective
7
6
5
4
•Administerprescribedanalgesia•Ward doctor review to prescribe if
required
3
2
1
•No action 0
Bolus Indicate if IV bolus given(P)aracetamol (O)pioid (Ot)her
Enteral (P)aracetamol (O)pioid (N)SAID (Ot)her
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
TEST REQUESTED
WARD/CLINICAL UNIT
SURNAME OF REQUESTING OFFICER (Please print)
Requ
esti
ng O
ffice
r
CONSULTANT/SENIOR MEDICAL OFFICER SURNAME (Please print) INITIALS
SURNAME OF REQUESTING DOCTOR
FIRST NAME
AUSLAB CODE
PROVIDER NUMBER
(Please print)
Req
uest
Det
ails
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
TEST REQUESTED
WARD/ CLINICAL UNIT
LAB NO
GESTATIONAL AGE K=
DOCTORS: Please complete ALL relevant areas in the red section
CLINICAL NOTES/MEDICATIONS
URGENT n TEL n PAGE n FAX n CONTACT NO
LAB USE ONLY
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Doc
tor
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Pati
ent D
etai
ls
PATIENT SURNAME
GENDER
HOSPITAL
UR NOUR PREFIX DATE OF BIRTHMF
(Please print or place sticker on this area) PATIENT FIRST NAME
CONTACT NOPATIENT ADDRESS
D D M M Y Y YY
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Coll
ecto
r SURNAME OF COLLECTING PERSON (Please print) INITIALS
I certify that I collected the accompanying sample from the above patient whose identity was confirmed by inquiry and/or examination of their nameband and that I labelled the sample immediately following collection.
Date Time AMSignature: Collected / / Collected PM
Med
icar
e D
etai
ls
MEDICARE NUMBER
IRN
EXPHEALTH FUND NAME
VETERANS AFFAIRS
MEDICARE ASSIGNMENT FORM (Section 20A of the Health Insurance Act 1973) I offer to assign my rights to benefits to the approved pathology practitioner who will render the requested pathology service(s), and any eligible pathologist determinable service(s) established as necessary by the practitioner
Patient Signature X Date
PRACTITIONERS USE ONLY (Reason patient cannot sign)
Patient status at the time of the service or when specimen collected (please tick) Yes
n Private patient in a private hospital or approved day hospital facility nn Private patient in a recognised hospital nn Public patient in a recognised hospital nn Outpatient in a recognised hospital nn Bulk Bill Rural & Remote COAG n
PHLEBOTOMY USE ONLY
Indigenous statusAboriginal nTSI nBoth n
Non- Indigenous nNot stated n
/ /
Coll
ecti
on D
etai
ls
COLLECTION CODE CONTAINERS COLLECTED (No of Tubes)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency
at
DO
nO
t wr
ite in
this
bin
Din
g m
ar
gin
DO
nO
t w
rit
e in
th
is b
inD
ing
ma
rg
in
CE
WT
®
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M F I
Children’s Early Warning Tool (CEWT®)
Facility:
•
• •
in action box• •
infusion chart
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
• Full CEWT score = Respiratory rate + Respiratory distress + O2 + O
2Saturation+Temperature+
Heartrate+Bloodpressure+Capillaryrefilltime+Levelof consciousness.• AFullCEWTscoreandapainscore(p4)mustbecalculated
› on admission › once per shift (minimum 8th hourly) › if patientisdeteriorating(increasingscoreoryouareconcernedaboutthepatient).
• When graphing observations, place a dot ( )intheappropriateboxandjoin totheprecedingdot(e.g. ).Forbloodpressure,usethesymbolsindicated( ).
• Anyobservationoutsidetherangeof thegraph,youmustwritethenumber.• ScoreeachobservationbyreferringtotheCEWTScoreLegendorbyaligningthedotwiththescoring
columnsoneithersideof thegraph.AddupallobservationscorestocalculatetheTotalCEWTscoreandrecordthisintheTotalCEWTscorerow,evenif thescoreiszero.
• Forabnormalobservations,youmustcontinuetocheckuntilnormal.• Asidefromtheabove,doappropriateobservationsatanappropriatefrequencyforthepatient’sclinicalstatus.
General Instructions
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
:
Signature:
• Modifications can ONLYbemadeonthebasisof chronicabnormalphysiology.• ModificationscanonlybeauthorisedbySMO/registrar/PHO(orequivalent).• ModificationsmustbeassessedandrewrittenwitheachnewCEWTchart.
Modifications Use if abnormal observations are tolerated for patient
Scoring Note: observations outside the modified range revert to the original score on CEWT
Example: if O2 saturations > 90% are tolerated (score of
zero)andtheO2 saturations drop to 90%, it would score 1
NB: tick modifications box at bottom of page 3 to indicate modifications are in use
Write the acceptable range (will score zero) below:Diagnosis which justifies modification (e.g.cysticfibrosis):
Page 4 of 4Page 1 of 4
Interventions
A
B
C
D
E
F
G
If an intervention is administered, record here and note letter in Interventions row over page in appropriate time column
Additional ObservationsDate
Time
Weight (kg)
Other:
Height (cm)
Respiratory Rate to breaths/min
O2Saturation to %
O2 Flow Rate to L/min
SystolicBP to mmHg
Heart Rate to beats/min
12 YEAR
S AN
D O
LDER
≥ 12 years12 years and Older
References: FPS-R:HicksCLetal.,PAIN2001;93:173.©2001InternationalAssociationfortheStudyof Pain,reproducedwithpermission.www.iasp-pain.org/FPSR
Numerical
Askchildtotelltheirlevelof pain from scale
The Faces Pain Scale – Revised (FPS-R)
Suggested age: 3+ years (or if unable to use numerical)
“Thesefacesshowhowmuchsomethingcanhurt.Thisface[pointtoleft-mostface]showsnopain.Thefacesshowmoreandmorepain[pointtoeachfromlefttoright]uptothisone[pointtoright-mostface]–itshowsverymuchpain.Pointtothefacethatshowshowmuchyouhurt[rightnow].”
0 2 4 6 8 10
For tertiary and secondary facilities
TEr
TIAr
y AN
D S
EC
oN
DA
ry
Pain Assessment Chart Date
Time Actions: Pain Score
•Urgentregistrarreview.Consideropioids.ObtainafullCEWTscore.
•ContactAcutePainServiceif pain remains severe after permitted interventions
10
9
8
•Administerprescribedanalgesia•Obtain a full CEWT score•Registrar review if no improvement•ConsiderreferraltoAcutePainServiceif interventionsineffective
7
6
5
4
•Administerprescribedanalgesia•Ward doctor review to prescribe if
required
3
2
1
•No action 0
Bolus Indicate if IV bolus given(P)aracetamol (O)pioid (Ot)her
Enteral (P)aracetamol (O)pioid (N)SAID (Ot)her
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
TEST REQUESTED
WARD/CLINICAL UNIT
SURNAME OF REQUESTING OFFICER (Please print)
Requ
esti
ng O
ffice
r
V131018PU
I certify that I collected the accompanying specimen from the above patient whose identity was confirmed by enquiry and/or examination of their name band and that I labelled the specimen immediately following collection and before leaving the patient.
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
SST
CITRATE
PST
OTHER
REC’D TIME INITIALS
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Page 4 of 4Page 1 of 4
G
If an
record
in
ry
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
SST
CITRATE
PST
OTHER
REC’D TIME INITIALS
Neurological Pain/Epidural/Patient Controlled AnalgesiaPage 4 of 4Page 1 of 4
If an
record
in
ry
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
V131018PU
at
CONSULTANT/SENIOR MEDICAL OFFICER SURNAME (Please print) INITIALS
SURNAME OF REQUESTING DOCTOR
FIRST NAME
AUSLAB CODE
PROVIDER NUMBER
(Please print)
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
GESTATIONAL AGE K=CLINICAL NOTES/MEDICATIONS
URGENT n TEL n PAGE n FAX n CONTACT NO
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Doc
tor
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Pati
ent D
etai
ls
PATIENT SURNAME
GENDER
HOSPITAL
UR NOUR PREFIXMF
(Please print or place sticker on this area)
PATIENT ADDRESS
D
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Coll
ecto
r SURNAME OF COLLECTING PERSON (Please print) INITIALS
I certify that I collected the accompanying sample from the above patient whose identity was confirmed by inquiry and/or examination of their nameband and that I labelled the sample immediately following collection.
Date Time AMSignature: Collected / / Collected PM
Med
icar
e D
etai
ls
MEDICARE NUMBER
IRN
EXPHEALTH FUND NAME
VETERANS AFFAIRS
MEDICARE ASSIGNMENT FORM (Section 20A of the Health Insurance Act 1973) I offer to assign my rights to benefits to the approved pathology practitioner who will render the requested pathology service(s), and any eligible pathologist determinable service(s) established as necessary by the practitioner
Patient Signature X Date
PRACTITIONERS USE ONLY (Reason patient cannot sign)
n n Private patient in a recognised hospital n Public patient in a recognised hospital n Outpatient in a recognised hospital n Bulk Bill Rural & Remote COAG
Indigenous statusAboriginal nTSI nBoth n
Non- Indigenous nNot stated n
/ /
Coll
ecti
on D
etai
ls
COLLECTION CODE CONTAINERS COLLECTED (No of Tubes)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency
at
DO
nO
t wr
ite in
this
bin
Din
g m
ar
gin
DO
nO
t w
rit
e in
th
is b
inD
ing
ma
rg
in
CE
WT
®
Facility:
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
•
• › › ›
• When graphing observations, place a dot ( )intheappropriateboxandjoin totheprecedingdot(e.g. ).Forbloodpressure,usethesymbolsindicated( ).
• Anyobservationoutsidetherangeof thegraph,youmustwritethenumber.• ScoreeachobservationbyreferringtotheCEWTScoreLegendorbyaligningthedotwiththescoring
columnsoneithersideof thegraph.AddupallobservationscorestocalculatetheTotalCEWTscoreandrecordthisintheTotalCEWTscorerow,evenif thescoreiszero.
• Forabnormalobservations,youmustcontinuetocheckuntilnormal.• Asidefromtheabove,doappropriateobservationsatanappropriatefrequencyforthepatient’sclinicalstatus.
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
:
Signature:
• Modifications can ONLYbemadeonthebasisof chronicabnormalphysiology.• ModificationscanonlybeauthorisedbySMO/registrar/PHO(orequivalent).• ModificationsmustbeassessedandrewrittenwitheachnewCEWTchart.
Modifications Use if abnormal observations are tolerated for patient
Scoring Note: observations outside the modified range revert to the original score on CEWT
Example: if O2 saturations > 90% are tolerated (score of
zero)andtheO2 saturations drop to 90%, it would score 1
NB: tick modifications box at bottom of page 3 to indicate modifications are in use
Write the acceptable range (will score zero) below:Diagnosis which justifies modification (e.g.cysticfibrosis):
Page 4 of 4Page 1 of 4
Interventions
A
B
C
D
E
F
G
If an intervention is administered, record here and note letter in Interventions row over page in appropriate time column
Additional ObservationsDate
Time
Weight (kg)
Other:
Height (cm)
Respiratory Rate to breaths/min
O2Saturation to %
O2 Flow Rate to L/min
SystolicBP to mmHg
Heart Rate to beats/min
12 YEAR
S AN
D O
LDER
References: FPS-R:HicksCLetal.,PAIN2001;93:173.©2001InternationalAssociationfortheStudyof Pain,reproducedwithpermission.www.iasp-pain.org/FPSR
8 9 10Worst Pain
The Faces Pain Scale – Revised (FPS-R)
Suggested age: 3+ years (or if unable to use numerical)
“Thesefacesshowhowmuchsomethingcanhurt.Thisface[pointtoleft-mostface]showsnopain.Thefacesshowmoreandmorepain[pointtoeachfromlefttoright]uptothisone[pointtoright-mostface]–itshowsverymuchpain.Pointtothefacethatshowshowmuchyouhurt[rightnow].”
0 2 4 6 8 10
TEr
TIAr
y AN
D S
EC
oN
DA
ry
Pain Assessment Chart Date
Time Actions: Pain Score
•Urgentregistrarreview.Consideropioids.ObtainafullCEWTscore.
•ContactAcutePainServiceif pain remains severe after permitted interventions
10
9
8
•Administerprescribedanalgesia•Obtain a full CEWT score•Registrar review if no improvement•ConsiderreferraltoAcutePainServiceif interventionsineffective
7
6
5
4
•Administerprescribedanalgesia•Ward doctor review to prescribe if
required
3
2
1
•No action 0
Bolus Indicate if IV bolus given(P)aracetamol (O)pioid (Ot)her
Enteral (P)aracetamol (O)pioid (N)SAID (Ot)her
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
SURNAME OF REQUESTING OFFICER (Please print)
Requ
esti
ng O
ffice
r
CONSULTANT/SENIOR MEDICAL OFFICER SURNAME (Please print) INITIALS
SURNAME OF REQUESTING DOCTOR
FIRST NAME
AUSLAB CODE
PROVIDER NUMBER
(Please print)
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
GESTATIONAL AGE K=CLINICAL NOTES/MEDICATIONS
URGENT n TEL n PAGE n FAX n CONTACT NO
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Doc
tor
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Pati
ent D
etai
ls
PATIENT SURNAME
GENDER
HOSPITAL
UR NOUR PREFIXMF
(Please print or place sticker on this area)
PATIENT ADDRESS
D
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Coll
ecto
r SURNAME OF COLLECTING PERSON (Please print) INITIALS
I certify that I collected the accompanying sample from the above patient whose identity was confirmed by inquiry and/or examination of their nameband and that I labelled the sample immediately following collection.
Date Time AMSignature: Collected / / Collected PM
Med
icar
e D
etai
ls
MEDICARE NUMBER
IRN
EXPHEALTH FUND NAME
VETERANS AFFAIRS
MEDICARE ASSIGNMENT FORM (Section 20A of the Health Insurance Act 1973) I offer to assign my rights to benefits to the approved pathology practitioner who will render the requested pathology service(s), and any eligible pathologist determinable service(s) established as necessary by the practitioner
Patient Signature X Date
PRACTITIONERS USE ONLY (Reason patient cannot sign)
n n Private patient in a recognised hospital n Public patient in a recognised hospital n Outpatient in a recognised hospital n Bulk Bill Rural & Remote COAG
Indigenous statusAboriginal nTSI nBoth n
Non- Indigenous nNot stated n
/ /
Coll
ecti
on D
etai
ls
COLLECTION CODE CONTAINERS COLLECTED (No of Tubes)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency
at
DO
nO
t wr
ite in
this
bin
Din
g m
ar
gin
DO
nO
t w
rit
e in
th
is b
inD
ing
ma
rg
in
CE
WT
®
Facility:
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
•
• › › ›
• totheprecedingdot(e.g. ).Forbloodpressure,usethesymbolsindicated( ).
• Anyobservationoutsidetherangeof thegraph,youmustwritethenumber.• ScoreeachobservationbyreferringtotheCEWTScoreLegendorbyaligningthedotwiththescoring
columnsoneithersideof thegraph.AddupallobservationscorestocalculatetheTotalCEWTscoreandrecordthisintheTotalCEWTscorerow,evenif thescoreiszero.
• Forabnormalobservations,youmustcontinuetocheckuntilnormal.• Asidefromtheabove,doappropriateobservationsatanappropriatefrequencyforthepatient’sclinicalstatus.
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
:
Signature:
• Modifications can ONLYbemadeonthebasisof chronicabnormalphysiology.• ModificationscanonlybeauthorisedbySMO/registrar/PHO(orequivalent).• ModificationsmustbeassessedandrewrittenwitheachnewCEWTchart.
Modifications Use if abnormal observations are tolerated for patient
Scoring Note: observations outside the modified range revert to the original score on CEWT
Example: if O2 saturations > 90% are tolerated (score of
zero)andtheO2 saturations drop to 90%, it would score 1
NB: tick modifications box at bottom of page 3 to indicate modifications are in use
Write the acceptable range (will score zero) below:Diagnosis which justifies modification (e.g.cysticfibrosis):
Page 4 of 4Page 1 of 4
Interventions
A
B
C
D
E
F
G
If an intervention is administered, record here and note letter in Interventions row over page in appropriate time column
Additional ObservationsDate
Time
Weight (kg)
Other:
Height (cm)
Respiratory Rate to breaths/min
O2Saturation to %
O2 Flow Rate to L/min
SystolicBP to mmHg
Heart Rate to beats/min
12 YEAR
S AN
D O
LDER
References: FPS-R:HicksCLetal.,PAIN2001;93:173.©2001InternationalAssociationfortheStudyof Pain,reproducedwithpermission.www.iasp-pain.org/FPSR
8 9 10Worst Pain
The Faces Pain Scale – Revised (FPS-R)
Suggested age: 3+ years (or if unable to use numerical)
“Thesefacesshowhowmuchsomethingcanhurt.Thisface[pointtoleft-mostface]showsnopain.Thefacesshowmoreandmorepain[pointtoeachfromlefttoright]uptothisone[pointtoright-mostface]–itshowsverymuchpain.Pointtothefacethatshowshowmuchyouhurt[rightnow].”
0 2 4 6 8 10
TEr
TIAr
y AN
D S
EC
oN
DA
ry
Pain Assessment Chart Date
Time Actions: Pain Score
•Urgentregistrarreview.Consideropioids.ObtainafullCEWTscore.
•ContactAcutePainServiceif pain remains severe after permitted interventions
10
9
8
•Administerprescribedanalgesia•Obtain a full CEWT score•Registrar review if no improvement•ConsiderreferraltoAcutePainServiceif interventionsineffective
7
6
5
4
•Administerprescribedanalgesia•Ward doctor review to prescribe if
required
3
2
1
•No action 0
Bolus Indicate if IV bolus given(P)aracetamol (O)pioid (Ot)her
Enteral (P)aracetamol (O)pioid (N)SAID (Ot)her
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
SURNAME OF REQUESTING OFFICER (Please print)
Requ
esti
ng O
ffice
r
V131018PU
I certify that I collected the accompanying specimen from the above patient whose identity was confirmed by enquiry and/or examination of their name band and that I labelled the specimen immediately following collection and before leaving the patient.
LAB NO
DOCTORS: Please complete ALL relevant areas in the red section
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
GENDER
HOSPITAL
UR NOUR PREFIX DATE OF BIRTH
FD D M M Y Y YY
Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
CITRATE
PST
ABG
FL OX
REC’D TIME
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency (Affix identification label here)
URN:
Family name:Children’s Early
Warning Tool (CEWT®)
Pain Assessment Chart Instructions• If you are concerned about the patient’s pain but
• Tick appropriate pain assessment tool
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
Authorised by
Signature:
Page 4 of 4Page 1 of 4
E
F
G
row over page in appropriate time column
Time
Weight (kg)
Other:
Height (cm)
≥ 12
AN
D S
EC
oN
DA
ry
1926_v4.00_121101_SW141-SW148_CEWT.indd 2
WARD/ CLINICAL UNIT
LAB NO
DOCTORS: Please complete ALL relevant areas in the red section
LAB USE ONLY
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
GENDER
HOSPITAL
UR NOUR PREFIX DATE OF BIRTHM
D D M M Y Y YY
Self Collect Assist Others Patient Fasting PEI
PST
FL OX
REC’D TIME
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency (Affix identification label here)
URN:
Family name:
Given name(s):
Children’s Early Warning Tool (CEWT®)
Pain Assessment Chart Instructions• If you are concerned about the patient’s pain but
• Tick appropriate pain assessment tool•
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
Authorised by
Page 4 of 4Page 1 of 4
E
F
G
in appropriate time column
Weight (kg)
Other:
Height (cm)
≥ 12
ry
1926_v4.00_121101_SW141-SW148_CEWT.indd 2
V131018PU
E
F
G
row over page in appropriate time column
1926_v4.00_121101_SW141-SW148_CEWT.indd 2
E
F
G
in appropriate time column
1926_v4.00_121101_SW141-SW148_CEWT.indd 2
at
CONSULTANT/SENIOR MEDICAL OFFICER SURNAME (Please print) INITIALS
SURNAME OF REQUESTING DOCTOR
FIRST NAME
AUSLAB CODE
PROVIDER NUMBER
(Please print)
Req
uest
Det
ails
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
TEST REQUESTED
WARD/ CLINICAL UNIT
LAB NO
GESTATIONAL AGE K=
DOCTORS: Please complete ALL relevant areas in the red section
CLINICAL NOTES/MEDICATIONS
URGENT n TEL n PAGE n FAX n CONTACT NO
LAB USE ONLY
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Doc
tor
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Pati
ent D
etai
ls
PATIENT SURNAME
GENDER
HOSPITAL
UR NOUR PREFIX DATE OF BIRTHMF
(Please print or place sticker on this area) PATIENT FIRST NAME
CONTACT NOPATIENT ADDRESS
D D M M Y Y YY
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Coll
ecto
r SURNAME OF COLLECTING PERSON (Please print) INITIALS
I certify that I collected the accompanying sample from the above patient whose identity was confirmed by inquiry and/or examination of their nameband and that I labelled the sample immediately following collection.
Date Time AMSignature: Collected / / Collected PM
Med
icar
e D
etai
ls
MEDICARE NUMBER
IRN
EXPHEALTH FUND NAME
VETERANS AFFAIRS
MEDICARE ASSIGNMENT FORM (Section 20A of the Health Insurance Act 1973) I offer to assign my rights to benefits to the approved pathology practitioner who will render the requested pathology service(s), and any eligible pathologist determinable service(s) established as necessary by the practitioner
Patient Signature X Date
PRACTITIONERS USE ONLY (Reason patient cannot sign)
Patient status at the time of the service or when specimen collected (please tick) Yes
n Private patient in a private hospital or approved day hospital facility nn Private patient in a recognised hospital nn Public patient in a recognised hospital nn Outpatient in a recognised hospital nn Bulk Bill Rural & Remote COAG n
PHLEBOTOMY USE ONLY
Indigenous statusAboriginal nTSI nBoth n
Non- Indigenous nNot stated n
/ /
Coll
ecti
on D
etai
ls
COLLECTION CODE CONTAINERS COLLECTED (No of Tubes)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency
at
DO
nO
t
CE
WT
®
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M F I
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M F I
Children’s Early Warning Tool (CEWT®)
Facility:
Pain Assessment Chart Instructions• If you are concerned about the patient’s pain but
they do not fit the below criteria notify medical officer• Tick appropriate pain assessment tool• For any score in coloured zone follow instructions
in action box• Note bolus or adjunctive pain relief in table• If on opioid / analgesia infusions, use pain
infusion chart
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
• Full CEWT score = Respiratory rate + Respiratory distress + O2 + O
2Saturation+Temperature+
Heartrate+Bloodpressure+Capillaryrefilltime+Levelof consciousness.• AFullCEWTscoreandapainscore(p4)mustbecalculated
› on admission › once per shift (minimum 8th hourly) › if patientisdeteriorating(increasingscoreoryouareconcernedaboutthepatient).
• When graphing observations, place a dot ( )intheappropriateboxandjoin totheprecedingdot(e.g. ).Forbloodpressure,usethesymbolsindicated( ).
• Anyobservationoutsidetherangeof thegraph,youmustwritethenumber.• ScoreeachobservationbyreferringtotheCEWTScoreLegendorbyaligningthedotwiththescoring
columnsoneithersideof thegraph.AddupallobservationscorestocalculatetheTotalCEWTscoreandrecordthisintheTotalCEWTscorerow,evenif thescoreiszero.
• Forabnormalobservations,youmustcontinuetocheckuntilnormal.• Asidefromtheabove,doappropriateobservationsatanappropriatefrequencyforthepatient’sclinicalstatus.
General Instructions
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
:
Signature:
• Modifications can ONLYbemadeonthebasisof chronicabnormalphysiology.• ModificationscanonlybeauthorisedbySMO/registrar/PHO(orequivalent).• ModificationsmustbeassessedandrewrittenwitheachnewCEWTchart.
Modifications Use if abnormal observations are tolerated for patient
Scoring Note: observations outside the modified range revert to the original score on CEWT
Example: if O2 saturations > 90% are tolerated (score of
zero)andtheO2 saturations drop to 90%, it would score 1
NB: tick modifications box at bottom of page 3 to indicate modifications are in use
Write the acceptable range (will score zero) below:Diagnosis which justifies modification (e.g.cysticfibrosis):
Page 4 of 4Page 1 of 4
Interventions
A
B
C
D
E
F
G
If an intervention is administered, record here and note letter in Interventions row over page in appropriate time column
Additional ObservationsDate
Time
Weight (kg)
Other:
Height (cm)
Respiratory Rate to breaths/min
O2Saturation to %
O2 Flow Rate to L/min
SystolicBP to mmHg
Heart Rate to beats/min
12 YEAR
S AN
D O
LDER
≥ 12 years
≥ 12 years12 years and Older
References: FPS-R:HicksCLetal.,PAIN2001;93:173.©2001InternationalAssociationfortheStudyof Pain,reproducedwithpermission.www.iasp-pain.org/FPSR
Pain Assessment Tools Select(withtick)appropriatepainassessmenttool
NumericalSuggested age: 7+ years
Askchildtotelltheirlevelof pain from scale
0 7 8 9 101 2 3 4 65No Pain Moderate Pain Worst Pain
The Faces Pain Scale – Revised (FPS-R)
Suggested age: 3+ years (or if unable to use numerical)
“Thesefacesshowhowmuchsomethingcanhurt.Thisface[pointtoleft-mostface]showsnopain.Thefacesshowmoreandmorepain[pointtoeachfromlefttoright]uptothisone[pointtoright-mostface]–itshowsverymuchpain.Pointtothefacethatshowshowmuchyouhurt[rightnow].”
0 2 4 6 8 10
For tertiary and secondary facilities
TEr
TIAr
y AN
D S
EC
oN
DA
ry
Pain Assessment Chart Date
Time Actions: Pain Score
•Urgentregistrarreview.Consideropioids.ObtainafullCEWTscore.
•ContactAcutePainServiceif pain remains severe after permitted interventions
10
9
8
•Administerprescribedanalgesia•Obtain a full CEWT score•Registrar review if no improvement•ConsiderreferraltoAcutePainServiceif interventionsineffective
7
6
5
4
•Administerprescribedanalgesia•Ward doctor review to prescribe if
required
3
2
1
•No action 0
Bolus Indicate if IV bolus given(P)aracetamol (O)pioid (Ot)her
Enteral (P)aracetamol (O)pioid (N)SAID (Ot)her
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
TEST REQUESTED
WARD/CLINICAL UNIT
SURNAME OF REQUESTING OFFICER (Please print)
Requ
esti
ng O
ffice
r
CONSULTANT/SENIOR MEDICAL OFFICER SURNAME (Please print) INITIALS
SURNAME OF REQUESTING DOCTOR
FIRST NAME
AUSLAB CODE
PROVIDER NUMBER
(Please print)
Req
uest
Det
ails
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
TEST REQUESTED
WARD/ CLINICAL UNIT
LAB NO
GESTATIONAL AGE K=
DOCTORS: Please complete ALL relevant areas in the red section
CLINICAL NOTES/MEDICATIONS
URGENT n TEL n PAGE n FAX n CONTACT NO
LAB USE ONLY
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Doc
tor
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Pati
ent D
etai
ls
PATIENT SURNAME
GENDER
HOSPITAL
UR NOUR PREFIX DATE OF BIRTHMF
(Please print or place sticker on this area) PATIENT FIRST NAME
CONTACT NOPATIENT ADDRESS
D D M M Y Y YY
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Coll
ecto
r SURNAME OF COLLECTING PERSON (Please print) INITIALS
I certify that I collected the accompanying sample from the above patient whose identity was confirmed by inquiry and/or examination of their nameband and that I labelled the sample immediately following collection.
Date Time AMSignature: Collected / / Collected PM
Med
icar
e D
etai
ls
MEDICARE NUMBER
IRN
EXPHEALTH FUND NAME
VETERANS AFFAIRS
MEDICARE ASSIGNMENT FORM (Section 20A of the Health Insurance Act 1973) I offer to assign my rights to benefits to the approved pathology practitioner who will render the requested pathology service(s), and any eligible pathologist determinable service(s) established as necessary by the practitioner
Patient Signature X Date
PRACTITIONERS USE ONLY (Reason patient cannot sign)
Patient status at the time of the service or when specimen collected (please tick) Yes
n Private patient in a private hospital or approved day hospital facility nn Private patient in a recognised hospital nn Public patient in a recognised hospital nn Outpatient in a recognised hospital nn Bulk Bill Rural & Remote COAG n
PHLEBOTOMY USE ONLY
Indigenous statusAboriginal nTSI nBoth n
Non- Indigenous nNot stated n
/ /
Coll
ecti
on D
etai
ls
COLLECTION CODE CONTAINERS COLLECTED (No of Tubes)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency
at
DO
nO
t
CE
WT
®
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M F I
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M F I
Children’s Early Warning Tool (CEWT®)
Facility:
Pain Assessment Chart Instructions• If you are concerned about the patient’s pain but
they do not fit the below criteria notify medical officer• Tick appropriate pain assessment tool• For any score in coloured zone follow instructions
in action box• Note bolus or adjunctive pain relief in table• If on opioid / analgesia infusions, use pain
infusion chart
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
• Full CEWT score = Respiratory rate + Respiratory distress + O2 + O
2Saturation+Temperature+
Heartrate+Bloodpressure+Capillaryrefilltime+Levelof consciousness.• AFullCEWTscoreandapainscore(p4)mustbecalculated
› on admission › once per shift (minimum 8th hourly) › if patientisdeteriorating(increasingscoreoryouareconcernedaboutthepatient).
• When graphing observations, place a dot ( )intheappropriateboxandjoin totheprecedingdot(e.g. ).Forbloodpressure,usethesymbolsindicated( ).
• Anyobservationoutsidetherangeof thegraph,youmustwritethenumber.• ScoreeachobservationbyreferringtotheCEWTScoreLegendorbyaligningthedotwiththescoring
columnsoneithersideof thegraph.AddupallobservationscorestocalculatetheTotalCEWTscoreandrecordthisintheTotalCEWTscorerow,evenif thescoreiszero.
• Forabnormalobservations,youmustcontinuetocheckuntilnormal.• Asidefromtheabove,doappropriateobservationsatanappropriatefrequencyforthepatient’sclinicalstatus.
General Instructions
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
:
Signature:
• Modifications can ONLYbemadeonthebasisof chronicabnormalphysiology.• ModificationscanonlybeauthorisedbySMO/registrar/PHO(orequivalent).• ModificationsmustbeassessedandrewrittenwitheachnewCEWTchart.
Modifications Use if abnormal observations are tolerated for patient
Scoring Note: observations outside the modified range revert to the original score on CEWT
Example: if O2 saturations > 90% are tolerated (score of
zero)andtheO2 saturations drop to 90%, it would score 1
NB: tick modifications box at bottom of page 3 to indicate modifications are in use
Write the acceptable range (will score zero) below:Diagnosis which justifies modification (e.g.cysticfibrosis):
Page 4 of 4Page 1 of 4
Interventions
A
B
C
D
E
F
G
If an intervention is administered, record here and note letter in Interventions row over page in appropriate time column
Additional ObservationsDate
Time
Weight (kg)
Other:
Height (cm)
Respiratory Rate to breaths/min
O2Saturation to %
O2 Flow Rate to L/min
SystolicBP to mmHg
Heart Rate to beats/min
12 YEAR
S AN
D O
LDER
≥ 12 years
≥ 12 years12 years and Older
References: FPS-R:HicksCLetal.,PAIN2001;93:173.©2001InternationalAssociationfortheStudyof Pain,reproducedwithpermission.www.iasp-pain.org/FPSR
Pain Assessment Tools Select(withtick)appropriatepainassessmenttool
NumericalSuggested age: 7+ years
Askchildtotelltheirlevelof pain from scale
0 7 8 9 101 2 3 4 65No Pain Moderate Pain Worst Pain
The Faces Pain Scale – Revised (FPS-R)
Suggested age: 3+ years (or if unable to use numerical)
“Thesefacesshowhowmuchsomethingcanhurt.Thisface[pointtoleft-mostface]showsnopain.Thefacesshowmoreandmorepain[pointtoeachfromlefttoright]uptothisone[pointtoright-mostface]–itshowsverymuchpain.Pointtothefacethatshowshowmuchyouhurt[rightnow].”
0 2 4 6 8 10
For tertiary and secondary facilities
TEr
TIAr
y AN
D S
EC
oN
DA
ry
Pain Assessment Chart Date
Time Actions: Pain Score
•Urgentregistrarreview.Consideropioids.ObtainafullCEWTscore.
•ContactAcutePainServiceif pain remains severe after permitted interventions
10
9
8
•Administerprescribedanalgesia•Obtain a full CEWT score•Registrar review if no improvement•ConsiderreferraltoAcutePainServiceif interventionsineffective
7
6
5
4
•Administerprescribedanalgesia•Ward doctor review to prescribe if
required
3
2
1
•No action 0
Bolus Indicate if IV bolus given(P)aracetamol (O)pioid (Ot)her
Enteral (P)aracetamol (O)pioid (N)SAID (Ot)her
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
TEST REQUESTED
WARD/CLINICAL UNIT
SURNAME OF REQUESTING OFFICER (Please print)
Requ
esti
ng O
ffice
r
V131018PU
I certify that I collected the accompanying specimen from the above patient whose identity was confirmed by enquiry and/or examination of their name band and that I labelled the specimen immediately following collection and before leaving the patient.
at
SURNAME OF REQUESTING DOCTOR
FIRST NAME
AUSLAB CODE
PROVIDER NUMBER
(Please print)
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
URGENT n TEL n PAGE n FAX n CONTACT NO
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Doc
tor
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Pati
ent D
etai
ls
PATIENT SURNAME
GENDER
HOSPITAL
UR NOUR PREFIX DATE OF BIRTHMF
(Please print or place sticker on this area) PATIENT FIRST NAME
CONTACT NOPATIENT ADDRESS
D D M M Y Y YY
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Coll
ecto
r SURNAME OF COLLECTING PERSON (Please print) INITIALS
I certify that I collected the accompanying sample from the above patient whose identity was confirmed by inquiry and/or examination of their nameband and that I labelled the sample immediately following collection.
Date Time AMSignature: Collected / / Collected PM
Med
icar
e D
etai
ls
MEDICARE NUMBER
IRN
EXPHEALTH FUND NAME
VETERANS AFFAIRS
MEDICARE ASSIGNMENT FORM (Section 20A of the Health Insurance Act 1973) I offer to assign my rights to benefits to the approved pathology practitioner who will render the requested pathology service(s), and any eligible pathologist determinable service(s) established as necessary by the practitioner
Patient Signature X Date
PRACTITIONERS USE ONLY (Reason patient cannot sign)
Patient status at the time of the service or when specimen collected (please tick) Yes
n Private patient in a private hospital or approved day hospital facility nn Private patient in a recognised hospital nn Public patient in a recognised hospital nn Outpatient in a recognised hospital nn Bulk Bill Rural & Remote COAG n
PHLEBOTOMY USE ONLY
Indigenous statusAboriginal nTSI nBoth n
Non- Indigenous nNot stated n
/ /
Coll
ecti
on D
etai
ls
COLLECTION CODE CONTAINERS COLLECTED (No of Tubes)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency
at
DO
nO
t
CE
WT
®
Facility:
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
• Full CEWT score =
• › on admission › › if
•totheprecedingdot(e.g.
• Any• Scoreeachobservationby
columnsoneithersideof
• Forabnormalobservations,• Asidefromtheabove,do
General Instructions
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
:
Signature:
• Modifications can ONLY••
Modifications Use if
Scoring Note: observations outside the modified range revert to the original score on CEWT
Example: if O2 saturations > 90% are tolerated (score of
zero)andtheO2 saturations drop to 90%, it would score 1
NB: tick modifications box at bottom of page 3 to indicate modifications are in use
Write the acceptable range (will score zero) below:Diagnosis which justifies modification (e.g.cysticfibrosis):
Page 4 of 4Page 1 of 4
Interventions
A
B
C
D
E
F
G
If an intervention is administered, record here and note letter in Interventions row over page in appropriate time column
Additional ObservationsDate
Time
Weight (kg)
Other:
Height (cm)
Respiratory Rate to breaths/min
O2Saturation to %
O2 Flow Rate to L/min
SystolicBP to mmHg
Heart Rate to beats/min
12 YEAR
S AN
D O
LDER
References: FPS-R:HicksCLetal.,PAIN2001;93:173.©2001InternationalAssociationfortheStudyof Pain,reproducedwithpermission.www.iasp-pain.org/FPSRTEr
TIAr
y AN
D S
EC
oN
DA
ry
Date
Time Actions: Pain Score
•Urgentregistrarreview.Consideropioids.ObtainafullCEWTscore.
•ContactAcutePainServiceif pain remains severe after permitted interventions
10
9
8
•Administerprescribedanalgesia•Obtain a full CEWT score•Registrar review if no improvement•ConsiderreferraltoAcutePainServiceif interventionsineffective
7
6
5
4
•Administerprescribedanalgesia•Ward doctor review to prescribe if
required
3
2
1
•No action 0
Bolus Indicate if IV bolus given(P)aracetamol (O)pioid (Ot)her
Enteral (P)aracetamol (O)pioid (N)SAID (Ot)her
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
SURNAME OF REQUESTING OFFICER (Please print)
Requ
esti
ng O
ffice
r SURNAME OF REQUESTING DOCTOR
FIRST NAME
AUSLAB CODE
PROVIDER NUMBER
(Please print)
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
URGENT n TEL n PAGE n FAX n CONTACT NO
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Doc
tor
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Pati
ent D
etai
ls
PATIENT SURNAME
GENDER
HOSPITAL
UR NOUR PREFIX DATE OF BIRTHMF
(Please print or place sticker on this area) PATIENT FIRST NAME
CONTACT NOPATIENT ADDRESS
D D M M Y Y YY
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Coll
ecto
r SURNAME OF COLLECTING PERSON (Please print) INITIALS
I certify that I collected the accompanying sample from the above patient whose identity was confirmed by inquiry and/or examination of their nameband and that I labelled the sample immediately following collection.
Date Time AMSignature: Collected / / Collected PM
Med
icar
e D
etai
ls
MEDICARE NUMBER
IRN
EXPHEALTH FUND NAME
VETERANS AFFAIRS
MEDICARE ASSIGNMENT FORM (Section 20A of the Health Insurance Act 1973) I offer to assign my rights to benefits to the approved pathology practitioner who will render the requested pathology service(s), and any eligible pathologist determinable service(s) established as necessary by the practitioner
Patient Signature X Date
PRACTITIONERS USE ONLY (Reason patient cannot sign)
Patient status at the time of the service or when specimen collected (please tick) Yes
n Private patient in a private hospital or approved day hospital facility nn Private patient in a recognised hospital nn Public patient in a recognised hospital nn Outpatient in a recognised hospital nn Bulk Bill Rural & Remote COAG n
PHLEBOTOMY USE ONLY
Indigenous statusAboriginal nTSI nBoth n
Non- Indigenous nNot stated n
/ /
Coll
ecti
on D
etai
ls
COLLECTION CODE CONTAINERS COLLECTED (No of Tubes)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency
at
DO
nO
t
CE
WT
®
Facility:
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
• Full CEWT score =
• › on admission › › if
•totheprecedingdot(e.g.
• Any• Scoreeachobservationby
columnsoneithersideof
• Forabnormalobservations,• Asidefromtheabove,do
General Instructions
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
:
Signature:
• Modifications can ONLY••
Modifications Use if
Scoring Note: observations outside the modified range revert to the original score on CEWT
Example: if O2 saturations > 90% are tolerated (score of
zero)andtheO2 saturations drop to 90%, it would score 1
NB: tick modifications box at bottom of page 3 to indicate modifications are in use
(e.g.cysticfibrosis):
Page 4 of 4Page 1 of 4
Interventions
A
B
C
D
E
F
G
If an intervention is administered, record here and note letter in Interventions row over page in appropriate time column
Additional ObservationsDate
Time
Weight (kg)
Other:
Height (cm)
Respiratory Rate to breaths/min
O2Saturation to %
O2 Flow Rate to L/min
SystolicBP to mmHg
Heart Rate to beats/min
12 YEAR
S AN
D O
LDER
References: FPS-R:HicksCLetal.,PAIN2001;93:173.©2001InternationalAssociationfortheStudyof Pain,reproducedwithpermission.www.iasp-pain.org/FPSRTEr
TIAr
y AN
D S
EC
oN
DA
ry
Time Actions: Pain Score
•Urgentregistrarreview.Consideropioids.ObtainafullCEWTscore.
•ContactAcutePainServiceif pain remains severe after permitted interventions
10
9
8
•Administerprescribedanalgesia•Obtain a full CEWT score•Registrar review if no improvement•ConsiderreferraltoAcutePainServiceif interventionsineffective
7
6
5
4
•Administerprescribedanalgesia•Ward doctor review to prescribe if
required
3
2
1
•No action 0
Bolus Indicate if IV bolus given(P)aracetamol (O)pioid (Ot)her
Enteral (P)aracetamol (O)pioid (N)SAID (Ot)her
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
SURNAME OF REQUESTING OFFICER (Please print)
V131018PU
I certify that I collected the accompanying specimen from the above patient whose identity was confirmed by enquiry and/or examination of their name band and that I labelled the specimen immediately following collection and before leaving the patient.
at
CONSULTANT/SENIOR MEDICAL OFFICER SURNAME (Please print) INITIALS
SURNAME OF REQUESTING DOCTOR
FIRST NAME
AUSLAB CODE
PROVIDER NUMBER
(Please print)
Req
uest
Det
ails
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
TEST REQUESTED
WARD/ CLINICAL UNIT
LAB NO
GESTATIONAL AGE K=
DOCTORS: Please complete ALL relevant areas in the red section
CLINICAL NOTES/MEDICATIONS
URGENT n TEL n PAGE n FAX n CONTACT NO
LAB USE ONLY
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Doc
tor
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Pati
ent D
etai
ls
PATIENT SURNAME
GENDER
HOSPITAL
UR NOUR PREFIX DATE OF BIRTHMF
(Please print or place sticker on this area) PATIENT FIRST NAME
CONTACT NOPATIENT ADDRESS
D D M M Y Y YY
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Coll
ecto
r SURNAME OF COLLECTING PERSON (Please print) INITIALS
I certify that I collected the accompanying sample from the above patient whose identity was confirmed by inquiry and/or examination of their nameband and that I labelled the sample immediately following collection.
Date Time AMSignature: Collected / / Collected PM
Med
icar
e D
etai
ls
MEDICARE NUMBER
IRN
EXPHEALTH FUND NAME
VETERANS AFFAIRS
MEDICARE ASSIGNMENT FORM (Section 20A of the Health Insurance Act 1973) I offer to assign my rights to benefits to the approved pathology practitioner who will render the requested pathology service(s), and any eligible pathologist determinable service(s) established as necessary by the practitioner
Patient Signature X Date
PRACTITIONERS USE ONLY (Reason patient cannot sign)
Patient status at the time of the service or when specimen collected (please tick) Yes
n Private patient in a private hospital or approved day hospital facility nn Private patient in a recognised hospital nn Public patient in a recognised hospital nn Outpatient in a recognised hospital nn Bulk Bill Rural & Remote COAG n
PHLEBOTOMY USE ONLY
Indigenous statusAboriginal nTSI nBoth n
Non- Indigenous nNot stated n
/ /
Coll
ecti
on D
etai
ls
COLLECTION CODE CONTAINERS COLLECTED (No of Tubes)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency
at
DO
nO
t wr
ite in
this
bin
Din
g m
ar
gin
DO
nO
t w
rit
e in
th
is b
inD
ing
ma
rg
in
CE
WT
®
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M F I
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M F I
Children’s Early Warning Tool (CEWT®)
Facility:
Pain Assessment Chart Instructions• If you are concerned about the patient’s pain but
they do not fit the below criteria notify medical officer• Tick appropriate pain assessment tool• For any score in coloured zone follow instructions
in action box• Note bolus or adjunctive pain relief in table• If on opioid / analgesia infusions, use pain
infusion chart
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
• Full CEWT score = Respiratory rate + Respiratory distress + O2 + O
2Saturation+Temperature+
Heartrate+Bloodpressure+Capillaryrefilltime+Levelof consciousness.• AFullCEWTscoreandapainscore(p4)mustbecalculated
› on admission › once per shift (minimum 8th hourly) › if patientisdeteriorating(increasingscoreoryouareconcernedaboutthepatient).
• When graphing observations, place a dot ( )intheappropriateboxandjoin totheprecedingdot(e.g. ).Forbloodpressure,usethesymbolsindicated( ).
• Anyobservationoutsidetherangeof thegraph,youmustwritethenumber.• ScoreeachobservationbyreferringtotheCEWTScoreLegendorbyaligningthedotwiththescoring
columnsoneithersideof thegraph.AddupallobservationscorestocalculatetheTotalCEWTscoreandrecordthisintheTotalCEWTscorerow,evenif thescoreiszero.
• Forabnormalobservations,youmustcontinuetocheckuntilnormal.• Asidefromtheabove,doappropriateobservationsatanappropriatefrequencyforthepatient’sclinicalstatus.
General Instructions
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
:
Signature:
• Modifications can ONLYbemadeonthebasisof chronicabnormalphysiology.• ModificationscanonlybeauthorisedbySMO/registrar/PHO(orequivalent).• ModificationsmustbeassessedandrewrittenwitheachnewCEWTchart.
Modifications Use if abnormal observations are tolerated for patient
Scoring Note: observations outside the modified range revert to the original score on CEWT
Example: if O2 saturations > 90% are tolerated (score of
zero)andtheO2 saturations drop to 90%, it would score 1
NB: tick modifications box at bottom of page 3 to indicate modifications are in use
Write the acceptable range (will score zero) below:Diagnosis which justifies modification (e.g.cysticfibrosis):
Page 4 of 4Page 1 of 4
Interventions
A
B
C
D
E
F
G
If an intervention is administered, record here and note letter in Interventions row over page in appropriate time column
Additional ObservationsDate
Time
Weight (kg)
Other:
Height (cm)
Respiratory Rate to breaths/min
O2Saturation to %
O2 Flow Rate to L/min
SystolicBP to mmHg
Heart Rate to beats/min
12 YEAR
S AN
D O
LDER
≥ 12 years
≥ 12 years12 years and Older
References: FPS-R:HicksCLetal.,PAIN2001;93:173.©2001InternationalAssociationfortheStudyof Pain,reproducedwithpermission.www.iasp-pain.org/FPSR
Pain Assessment Tools Select(withtick)appropriatepainassessmenttool
NumericalSuggested age: 7+ years
Askchildtotelltheirlevelof pain from scale
0 7 8 9 101 2 3 4 65No Pain Moderate Pain Worst Pain
The Faces Pain Scale – Revised (FPS-R)
Suggested age: 3+ years (or if unable to use numerical)
“Thesefacesshowhowmuchsomethingcanhurt.Thisface[pointtoleft-mostface]showsnopain.Thefacesshowmoreandmorepain[pointtoeachfromlefttoright]uptothisone[pointtoright-mostface]–itshowsverymuchpain.Pointtothefacethatshowshowmuchyouhurt[rightnow].”
0 2 4 6 8 10
For tertiary and secondary facilities
TEr
TIAr
y AN
D S
EC
oN
DA
ry
Pain Assessment Chart Date
Time Actions: Pain Score
•Urgentregistrarreview.Consideropioids.ObtainafullCEWTscore.
•ContactAcutePainServiceif pain remains severe after permitted interventions
10
9
8
•Administerprescribedanalgesia•Obtain a full CEWT score•Registrar review if no improvement•ConsiderreferraltoAcutePainServiceif interventionsineffective
7
6
5
4
•Administerprescribedanalgesia•Ward doctor review to prescribe if
required
3
2
1
•No action 0
Bolus Indicate if IV bolus given(P)aracetamol (O)pioid (Ot)her
Enteral (P)aracetamol (O)pioid (N)SAID (Ot)her
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
TEST REQUESTED
WARD/CLINICAL UNIT
SURNAME OF REQUESTING OFFICER (Please print)
Requ
esti
ng O
ffice
r
CONSULTANT/SENIOR MEDICAL OFFICER SURNAME (Please print) INITIALS
SURNAME OF REQUESTING DOCTOR
FIRST NAME
AUSLAB CODE
PROVIDER NUMBER
(Please print)
Req
uest
Det
ails
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
TEST REQUESTED
WARD/ CLINICAL UNIT
LAB NO
GESTATIONAL AGE K=
DOCTORS: Please complete ALL relevant areas in the red section
CLINICAL NOTES/MEDICATIONS
URGENT n TEL n PAGE n FAX n CONTACT NO
LAB USE ONLY
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Doc
tor
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Pati
ent D
etai
ls
PATIENT SURNAME
GENDER
HOSPITAL
UR NOUR PREFIX DATE OF BIRTHMF
(Please print or place sticker on this area) PATIENT FIRST NAME
CONTACT NOPATIENT ADDRESS
D D M M Y Y YY
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Coll
ecto
r SURNAME OF COLLECTING PERSON (Please print) INITIALS
I certify that I collected the accompanying sample from the above patient whose identity was confirmed by inquiry and/or examination of their nameband and that I labelled the sample immediately following collection.
Date Time AMSignature: Collected / / Collected PM
Med
icar
e D
etai
ls
MEDICARE NUMBER
IRN
EXPHEALTH FUND NAME
VETERANS AFFAIRS
MEDICARE ASSIGNMENT FORM (Section 20A of the Health Insurance Act 1973) I offer to assign my rights to benefits to the approved pathology practitioner who will render the requested pathology service(s), and any eligible pathologist determinable service(s) established as necessary by the practitioner
Patient Signature X Date
PRACTITIONERS USE ONLY (Reason patient cannot sign)
Patient status at the time of the service or when specimen collected (please tick) Yes
n Private patient in a private hospital or approved day hospital facility nn Private patient in a recognised hospital nn Public patient in a recognised hospital nn Outpatient in a recognised hospital nn Bulk Bill Rural & Remote COAG n
PHLEBOTOMY USE ONLY
Indigenous statusAboriginal nTSI nBoth n
Non- Indigenous nNot stated n
/ /
Coll
ecti
on D
etai
ls
COLLECTION CODE CONTAINERS COLLECTED (No of Tubes)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency
at
DO
nO
t wr
ite in
this
bin
Din
g m
ar
gin
DO
nO
t w
rit
e in
th
is b
inD
ing
ma
rg
in
CE
WT
®
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M F I
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M F I
Children’s Early Warning Tool (CEWT®)
Facility:
Pain Assessment Chart Instructions• If you are concerned about the patient’s pain but
they do not fit the below criteria notify medical officer• Tick appropriate pain assessment tool• For any score in coloured zone follow instructions
in action box• Note bolus or adjunctive pain relief in table• If on opioid / analgesia infusions, use pain
infusion chart
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
• Full CEWT score = Respiratory rate + Respiratory distress + O2 + O
2Saturation+Temperature+
Heartrate+Bloodpressure+Capillaryrefilltime+Levelof consciousness.• AFullCEWTscoreandapainscore(p4)mustbecalculated
› on admission › once per shift (minimum 8th hourly) › if patientisdeteriorating(increasingscoreoryouareconcernedaboutthepatient).
• When graphing observations, place a dot ( )intheappropriateboxandjoin totheprecedingdot(e.g. ).Forbloodpressure,usethesymbolsindicated( ).
• Anyobservationoutsidetherangeof thegraph,youmustwritethenumber.• ScoreeachobservationbyreferringtotheCEWTScoreLegendorbyaligningthedotwiththescoring
columnsoneithersideof thegraph.AddupallobservationscorestocalculatetheTotalCEWTscoreandrecordthisintheTotalCEWTscorerow,evenif thescoreiszero.
• Forabnormalobservations,youmustcontinuetocheckuntilnormal.• Asidefromtheabove,doappropriateobservationsatanappropriatefrequencyforthepatient’sclinicalstatus.
General Instructions
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
:
Signature:
• Modifications can ONLYbemadeonthebasisof chronicabnormalphysiology.• ModificationscanonlybeauthorisedbySMO/registrar/PHO(orequivalent).• ModificationsmustbeassessedandrewrittenwitheachnewCEWTchart.
Modifications Use if abnormal observations are tolerated for patient
Scoring Note: observations outside the modified range revert to the original score on CEWT
Example: if O2 saturations > 90% are tolerated (score of
zero)andtheO2 saturations drop to 90%, it would score 1
NB: tick modifications box at bottom of page 3 to indicate modifications are in use
Write the acceptable range (will score zero) below:Diagnosis which justifies modification (e.g.cysticfibrosis):
Page 4 of 4Page 1 of 4
Interventions
A
B
C
D
E
F
G
If an intervention is administered, record here and note letter in Interventions row over page in appropriate time column
Additional ObservationsDate
Time
Weight (kg)
Other:
Height (cm)
Respiratory Rate to breaths/min
O2Saturation to %
O2 Flow Rate to L/min
SystolicBP to mmHg
Heart Rate to beats/min
12 YEAR
S AN
D O
LDER
≥ 12 years
≥ 12 years12 years and Older
References: FPS-R:HicksCLetal.,PAIN2001;93:173.©2001InternationalAssociationfortheStudyof Pain,reproducedwithpermission.www.iasp-pain.org/FPSR
Pain Assessment Tools Select(withtick)appropriatepainassessmenttool
NumericalSuggested age: 7+ years
Askchildtotelltheirlevelof pain from scale
0 7 8 9 101 2 3 4 65No Pain Moderate Pain Worst Pain
The Faces Pain Scale – Revised (FPS-R)
Suggested age: 3+ years (or if unable to use numerical)
“Thesefacesshowhowmuchsomethingcanhurt.Thisface[pointtoleft-mostface]showsnopain.Thefacesshowmoreandmorepain[pointtoeachfromlefttoright]uptothisone[pointtoright-mostface]–itshowsverymuchpain.Pointtothefacethatshowshowmuchyouhurt[rightnow].”
0 2 4 6 8 10
For tertiary and secondary facilities
TEr
TIAr
y AN
D S
EC
oN
DA
ry
Pain Assessment Chart Date
Time Actions: Pain Score
•Urgentregistrarreview.Consideropioids.ObtainafullCEWTscore.
•ContactAcutePainServiceif pain remains severe after permitted interventions
10
9
8
•Administerprescribedanalgesia•Obtain a full CEWT score•Registrar review if no improvement•ConsiderreferraltoAcutePainServiceif interventionsineffective
7
6
5
4
•Administerprescribedanalgesia•Ward doctor review to prescribe if
required
3
2
1
•No action 0
Bolus Indicate if IV bolus given(P)aracetamol (O)pioid (Ot)her
Enteral (P)aracetamol (O)pioid (N)SAID (Ot)her
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
TEST REQUESTED
WARD/CLINICAL UNIT
SURNAME OF REQUESTING OFFICER (Please print)
Requ
esti
ng O
ffice
r
V131018PU
I certify that I collected the accompanying specimen from the above patient whose identity was confirmed by enquiry and/or examination of their name band and that I labelled the specimen immediately following collection and before leaving the patient.
at
CONSULTANT/SENIOR MEDICAL OFFICER SURNAME (Please print) INITIALS
SURNAME OF REQUESTING DOCTOR
FIRST NAME
AUSLAB CODE
PROVIDER NUMBER
(Please print)
Req
uest
Det
ails
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
TEST REQUESTED
WARD/ CLINICAL UNIT
LAB NO
GESTATIONAL AGE K=
DOCTORS: Please complete ALL relevant areas in the red section
CLINICAL NOTES/MEDICATIONS
URGENT n TEL n PAGE n FAX n CONTACT NO
LAB USE ONLY
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Doc
tor
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Pati
ent D
etai
ls
PATIENT SURNAME
GENDER
HOSPITAL
UR NOUR PREFIX DATE OF BIRTHMF
(Please print or place sticker on this area) PATIENT FIRST NAME
CONTACT NOPATIENT ADDRESS
D D M M Y Y YY
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Coll
ecto
r SURNAME OF COLLECTING PERSON (Please print) INITIALS
I certify that I collected the accompanying sample from the above patient whose identity was confirmed by inquiry and/or examination of their nameband and that I labelled the sample immediately following collection.
Date Time AMSignature: Collected / / Collected PM
Med
icar
e D
etai
ls
MEDICARE NUMBER
IRN
EXPHEALTH FUND NAME
VETERANS AFFAIRS
MEDICARE ASSIGNMENT FORM (Section 20A of the Health Insurance Act 1973) I offer to assign my rights to benefits to the approved pathology practitioner who will render the requested pathology service(s), and any eligible pathologist determinable service(s) established as necessary by the practitioner
Patient Signature X Date
PRACTITIONERS USE ONLY (Reason patient cannot sign)
Patient status at the time of the service or when specimen collected (please tick) Yes
n Private patient in a private hospital or approved day hospital facility nn Private patient in a recognised hospital nn Public patient in a recognised hospital nn Outpatient in a recognised hospital nn Bulk Bill Rural & Remote COAG n
PHLEBOTOMY USE ONLY
Indigenous statusAboriginal nTSI nBoth n
Non- Indigenous nNot stated n
/ /
Coll
ecti
on D
etai
ls
COLLECTION CODE CONTAINERS COLLECTED (No of Tubes)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency
at
DO
nO
t wr
ite in
this
bin
Din
g m
ar
gin
DO
nO
t w
rit
e in
th
is b
inD
ing
ma
rg
in
CE
WT
®
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M F I
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M F I
Children’s Early Warning Tool (CEWT®)
Facility:
Pain Assessment Chart Instructions• If you are concerned about the patient’s pain but
they do not fit the below criteria notify medical officer• Tick appropriate pain assessment tool• For any score in coloured zone follow instructions
in action box• Note bolus or adjunctive pain relief in table• If on opioid / analgesia infusions, use pain
infusion chart
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
• Full CEWT score = Respiratory rate + Respiratory distress + O2 + O
2Saturation+Temperature+
Heartrate+Bloodpressure+Capillaryrefilltime+Levelof consciousness.• AFullCEWTscoreandapainscore(p4)mustbecalculated
› on admission › once per shift (minimum 8th hourly) › if patientisdeteriorating(increasingscoreoryouareconcernedaboutthepatient).
• When graphing observations, place a dot ( )intheappropriateboxandjoin totheprecedingdot(e.g. ).Forbloodpressure,usethesymbolsindicated( ).
• Anyobservationoutsidetherangeof thegraph,youmustwritethenumber.• ScoreeachobservationbyreferringtotheCEWTScoreLegendorbyaligningthedotwiththescoring
columnsoneithersideof thegraph.AddupallobservationscorestocalculatetheTotalCEWTscoreandrecordthisintheTotalCEWTscorerow,evenif thescoreiszero.
• Forabnormalobservations,youmustcontinuetocheckuntilnormal.• Asidefromtheabove,doappropriateobservationsatanappropriatefrequencyforthepatient’sclinicalstatus.
General Instructions
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
:
Signature:
• Modifications can ONLYbemadeonthebasisof chronicabnormalphysiology.• ModificationscanonlybeauthorisedbySMO/registrar/PHO(orequivalent).• ModificationsmustbeassessedandrewrittenwitheachnewCEWTchart.
Modifications Use if abnormal observations are tolerated for patient
Scoring Note: observations outside the modified range revert to the original score on CEWT
Example: if O2 saturations > 90% are tolerated (score of
zero)andtheO2 saturations drop to 90%, it would score 1
NB: tick modifications box at bottom of page 3 to indicate modifications are in use
Write the acceptable range (will score zero) below:Diagnosis which justifies modification (e.g.cysticfibrosis):
Page 4 of 4Page 1 of 4
Interventions
A
B
C
D
E
F
G
If an intervention is administered, record here and note letter in Interventions row over page in appropriate time column
Additional ObservationsDate
Time
Weight (kg)
Other:
Height (cm)
Respiratory Rate to breaths/min
O2Saturation to %
O2 Flow Rate to L/min
SystolicBP to mmHg
Heart Rate to beats/min
12 YEAR
S AN
D O
LDER
≥ 12 years
≥ 12 years12 years and Older
References: FPS-R:HicksCLetal.,PAIN2001;93:173.©2001InternationalAssociationfortheStudyof Pain,reproducedwithpermission.www.iasp-pain.org/FPSR
Pain Assessment Tools Select(withtick)appropriatepainassessmenttool
NumericalSuggested age: 7+ years
Askchildtotelltheirlevelof pain from scale
0 7 8 9 101 2 3 4 65No Pain Moderate Pain Worst Pain
The Faces Pain Scale – Revised (FPS-R)
Suggested age: 3+ years (or if unable to use numerical)
“Thesefacesshowhowmuchsomethingcanhurt.Thisface[pointtoleft-mostface]showsnopain.Thefacesshowmoreandmorepain[pointtoeachfromlefttoright]uptothisone[pointtoright-mostface]–itshowsverymuchpain.Pointtothefacethatshowshowmuchyouhurt[rightnow].”
0 2 4 6 8 10
For tertiary and secondary facilities
TEr
TIAr
y AN
D S
EC
oN
DA
ry
Pain Assessment Chart Date
Time Actions: Pain Score
•Urgentregistrarreview.Consideropioids.ObtainafullCEWTscore.
•ContactAcutePainServiceif pain remains severe after permitted interventions
10
9
8
•Administerprescribedanalgesia•Obtain a full CEWT score•Registrar review if no improvement•ConsiderreferraltoAcutePainServiceif interventionsineffective
7
6
5
4
•Administerprescribedanalgesia•Ward doctor review to prescribe if
required
3
2
1
•No action 0
Bolus Indicate if IV bolus given(P)aracetamol (O)pioid (Ot)her
Enteral (P)aracetamol (O)pioid (N)SAID (Ot)her
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
TEST REQUESTED
WARD/CLINICAL UNIT
SURNAME OF REQUESTING OFFICER (Please print)
Requ
esti
ng O
ffice
r
CONSULTANT/SENIOR MEDICAL OFFICER SURNAME (Please print) INITIALS
SURNAME OF REQUESTING DOCTOR
FIRST NAME
AUSLAB CODE
PROVIDER NUMBER
(Please print)
Req
uest
Det
ails
COPY REPORT TO ADDRESS
COPY REPORT TO: SURNAME (Please print) INITIALS
TEST REQUESTED
WARD/ CLINICAL UNIT
LAB NO
GESTATIONAL AGE K=
DOCTORS: Please complete ALL relevant areas in the red section
CLINICAL NOTES/MEDICATIONS
URGENT n TEL n PAGE n FAX n CONTACT NO
LAB USE ONLY
I have signed the above assignment to elect to have my pathology services bulk billed to Medicare.Code CONVM Billing Cat PA
Doc
tor
Copy
Requesting Date Doctor’s Signature X Requested
Self Determine/ /
Pati
ent D
etai
ls
PATIENT SURNAME
GENDER
HOSPITAL
UR NOUR PREFIX DATE OF BIRTHMF
(Please print or place sticker on this area) PATIENT FIRST NAME
CONTACT NOPATIENT ADDRESS
D D M M Y Y YY
Your doctor has recommended that you use Pathology Queensland. You are free to choose your own pathology provider. However, if your doctor has specified a particular pathologist on clinical grounds a Medicare rebate will only be payable if that pathologist performs the service. You should discuss this with your doctor.
Coll
ecto
r SURNAME OF COLLECTING PERSON (Please print) INITIALS
I certify that I collected the accompanying sample from the above patient whose identity was confirmed by inquiry and/or examination of their nameband and that I labelled the sample immediately following collection.
Date Time AMSignature: Collected / / Collected PM
Med
icar
e D
etai
ls
MEDICARE NUMBER
IRN
EXPHEALTH FUND NAME
VETERANS AFFAIRS
MEDICARE ASSIGNMENT FORM (Section 20A of the Health Insurance Act 1973) I offer to assign my rights to benefits to the approved pathology practitioner who will render the requested pathology service(s), and any eligible pathologist determinable service(s) established as necessary by the practitioner
Patient Signature X Date
PRACTITIONERS USE ONLY (Reason patient cannot sign)
Patient status at the time of the service or when specimen collected (please tick) Yes
n Private patient in a private hospital or approved day hospital facility nn Private patient in a recognised hospital nn Public patient in a recognised hospital nn Outpatient in a recognised hospital nn Bulk Bill Rural & Remote COAG n
PHLEBOTOMY USE ONLY
Indigenous statusAboriginal nTSI nBoth n
Non- Indigenous nNot stated n
/ /
Coll
ecti
on D
etai
ls
COLLECTION CODE CONTAINERS COLLECTED (No of Tubes)
Path QLD Collect Inpatient Path QLD Collect Outpatient Ward Collect Self Collect Self Collect Assist Others Patient Fasting PEI
EDTA
SST
CITRATE
PST
EDTA BBANK
BL Culture
ABG
FL OX
URINE
SWAB
HISTO
SLIDE
OTHER
REC’D TIME INITIALS
CALOUNDRAPathology QueenslandHSSA Health Services Support Agency
at
DO
nO
t wr
ite in
this
bin
Din
g m
ar
gin
DO
nO
t w
rit
e in
th
is b
inD
ing
ma
rg
in
CE
WT
®
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M F I
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M F I
Children’s Early Warning Tool (CEWT®)
Facility:
Pain Assessment Chart Instructions• If you are concerned about the patient’s pain but
they do not fit the below criteria notify medical officer• Tick appropriate pain assessment tool• For any score in coloured zone follow instructions
in action box• Note bolus or adjunctive pain relief in table• If on opioid / analgesia infusions, use pain
infusion chart
Fluid Balance Blood Glucose Neurovascular Neurological Pain/Epidural/Patient Controlled Analgesia
Other Charts
• Full CEWT score = Respiratory rate + Respiratory distress + O2 + O
2Saturation+Temperature+
Heartrate+Bloodpressure+Capillaryrefilltime+Levelof consciousness.• AFullCEWTscoreandapainscore(p4)mustbecalculated
› on admission › once per shift (minimum 8th hourly) › if patientisdeteriorating(increasingscoreoryouareconcernedaboutthepatient).
• When graphing observations, place a dot ( )intheappropriateboxandjoin totheprecedingdot(e.g. ).Forbloodpressure,usethesymbolsindicated( ).
• Anyobservationoutsidetherangeof thegraph,youmustwritethenumber.• ScoreeachobservationbyreferringtotheCEWTScoreLegendorbyaligningthedotwiththescoring
columnsoneithersideof thegraph.AddupallobservationscorestocalculatetheTotalCEWTscoreandrecordthisintheTotalCEWTscorerow,evenif thescoreiszero.
• Forabnormalobservations,youmustcontinuetocheckuntilnormal.• Asidefromtheabove,doappropriateobservationsatanappropriatefrequencyforthepatient’sclinicalstatus.
General Instructions
Doctor’s name (please print): Designation:
Authorised by(SMO/registrar/PHO):
Date / Time:/ /
:
Signature:
• Modifications can ONLYbemadeonthebasisof chronicabnormalphysiology.• ModificationscanonlybeauthorisedbySMO/registrar/PHO(orequivalent).• ModificationsmustbeassessedandrewrittenwitheachnewCEWTchart.
Modifications Use if abnormal observations are tolerated for patient
Scoring Note: observations outside the modified range revert to the original score on CEWT
Example: if O2 saturations > 90% are tolerated (score of
zero)andtheO2 saturations drop to 90%, it would score 1
NB: tick modifications box at bottom of page 3 to indicate modifications are in use
Write the acceptable range (will score zero) below:Diagnosis which justifies modification (e.g.cysticfibrosis):
Page 4 of 4Page 1 of 4
Interventions
A
B
C
D
E
F
G
If an intervention is administered, record here and note letter in Interventions row over page in appropriate time column
Additional ObservationsDate
Time
Weight (kg)
Other:
Height (cm)
Respiratory Rate to breaths/min
O2Saturation to %
O2 Flow Rate to L/min
SystolicBP to mmHg
Heart Rate to beats/min
12 YEAR
S AN
D O
LDER
≥ 12 years
≥ 12 years12 years and Older
References: FPS-R:HicksCLetal.,PAIN2001;93:173.©2001InternationalAssociationfortheStudyof Pain,reproducedwithpermission.www.iasp-pain.org/FPSR
Pain Assessment Tools Select(withtick)appropriatepainassessmenttool
NumericalSuggested age: 7+ years
Askchildtotelltheirlevelof pain from scale
0 7 8 9 101 2 3 4 65No Pain Moderate Pain Worst Pain
The Faces Pain Scale – Revised (FPS-R)
Suggested age: 3+ years (or if unable to use numerical)
“Thesefacesshowhowmuchsomethingcanhurt.Thisface[pointtoleft-mostface]showsnopain.Thefacesshowmoreandmorepain[pointtoeachfromlefttoright]uptothisone[pointtoright-mostface]–itshowsverymuchpain.Pointtothefacethatshowshowmuchyouhurt[rightnow].”
0 2 4 6 8 10
For tertiary and secondary facilities
TEr
TIAr
y AN
D S
EC
oN
DA
ry
Pain Assessment Chart Date
Time Actions: Pain Score
•Urgentregistrarreview.Consideropioids.ObtainafullCEWTscore.
•ContactAcutePainServiceif pain remains severe after permitted interventions
10
9
8
•Administerprescribedanalgesia•Obtain a full CEWT score•Registrar review if no improvement•ConsiderreferraltoAcutePainServiceif interventionsineffective
7
6
5
4
•Administerprescribedanalgesia•Ward doctor review to prescribe if
required
3
2
1
•No action 0
Bolus Indicate if IV bolus given(P)aracetamol (O)pioid (Ot)her
Enteral (P)aracetamol (O)pioid (N)SAID (Ot)her
1926_v4.00_121101_SW141-SW148_CEWT.indd 2 1/11/2012 9:58:58 AM
TEST REQUESTED
WARD/CLINICAL UNIT
SURNAME OF REQUESTING OFFICER (Please print)
Requ
esti
ng O
ffice
r
V131018PU
I certify that I collected the accompanying specimen from the above patient whose identity was confirmed by enquiry and/or examination of their name band and that I labelled the specimen immediately following collection and before leaving the patient.
Generic Pathology Form x 6 IMPO.indd 1 1/07/14 1:49 PM
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