Notice, record and prepare for the next visit.
Use the six core areas, add two focus areas of your own and record only what is useful for that visit. Leave anything blank when it does not help.
Record the visit
Add the date and your name, then use clear prompts and the same 1 to 5 scale to note what you noticed. Choose “not observed” when a prompt does not apply.
Track what matters
Note what was different, what happened beforehand and what appeared to help. You can also choose two optional focus areas of your own for the details that matter to the person and their care.
Prepare for the next visit
Review recent entries, note any follow-up and leave a useful starting point for next time. The review and appointment pages can also help organise questions for a GP or another professional.
The 1 to 5 scale
- 1
- Much worse than usual
- 2
- A little worse than usual
- 3
- Usual for them
- 4
- A little better than usual
- 5
- Much better than usual
- N/O
- Not observed
For observations and useful notes.
Medicine fields are for an observation, concern, refusal or conversation. They are not a dose schedule or medication administration record.
If someone may be in immediate danger or needs urgent medical help, contact the appropriate health or emergency service.
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