Integrated PREAC Form (Sample)
The Royal Brisbane & Women’s Hospital PATIENT IDENTIFICATION LABEL:
Health Service District UR No.: ___________________________________________
INTEGRATED PRE-ADMISSION Name: ___________________________________________
ASSESSMENT Address: ___________________________________________
FORM DOB: / / Male Female
(or affix patient ID label here)
TO THE PATIENT:
Please fill in all the shaded areas on pages 1 & 2. Circle ‘Y’ or ‘N’ as appropriate or place a
cross in the appropriate box. You can attend your GP to assist in completion of this form is
necessary.
Do you have any religious/cultural needs? No Yes Telephone Details:
Interpreter needed? No Yes Language spoken: Home:
Do you have difficulties with speech, hearing, touch or vision? No Yes Work:
Are these contact details correct? No Yes Other:
LOCAL DOCTOR (GP):
Dr’s Name: Telephone: Fax:
Address: Postcode:
REASON FOR ADMISSION/PROCEDURE
Pre-admission Date:
TCI Date:
INTEGRATED PRE ADMISSION ASSESSMENT FORM
Procedure Date:
Consultant: Admission Time: am pm
DAY OF ADMISSION (Nurse): (Instructions for SDCU or WARD)
SAFETY ALERTS: AT RISK OF FALLS? No Yes
Patient colonised/infected with multi-resistant organisms? No Yes
Medications taken? No Yes Patient belongings labelled? No Yes
QUESTIONS ABOUT YOUR GENERAL HEALTH
Past Medical History Please list any major problems with your health or surgery in the past 10 years (including any complications)
Illness or Surgery Type Date
A)
B)
C)
D)
Do you smoke? No Yes How many & for how long?
Have you ever smoked? When did you cease? No Yes
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ALLERGIES:
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RELEVANT HISTORY (Medical, Surgical, Social, Family)
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CURRENT MANAGEMENT PLAN:
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Signature: ________________________ Print Name: ___________________________
Date: ____/____/____ Designation: ___________________________
Do you have or have you ever had any of the following?
1. Asthma No Yes When?
2. Chronic or productive cough (bronchitis or bronchiectasis) No Yes Describe duration, colour & amount:
3. Home oxygen or CPAP No Yes Explain:
4. Shortness of breath or difficulty breathing (including when you are When?
No Yes
lying flat)
5. High blood pressure No Yes How long?
6. Chest pain, angina or heart attack No Yes Which/when?
7. Heart disease, artificial valve or pacemaker No Yes Which/when?
8. Rheumatic fever, heart murmur, irregular pulse or palpitations No Yes When?
9. Swelling of ankles No Yes
10. Blood disorder (eg. leukaemia or anaemia) No Yes What type/when?
11. Blood transfusion No Yes When?
12. Blood clots in legs or lungs No Yes Which/when?
13. Bleeding tendency or easy bruising No Yes When?
14. Diabetes No Yes How is it controlled?
15. Hepatitis, jaundice or cirrhosis No Yes What type/when?
16. Kidney disorder No Yes What type/when?
17. Gastric reflux, hiatus hernia or heartburn No Yes Which/when?
18. Epilepsy or other fits No Yes When?
19. Stroke No Yes What is affected?
20. Organ transplant No Yes Which/when?
21. Do you have an artificial joint, hearing aid, contact lenses No Yes Please specify:
22. Significant neck or back injury No Yes Explain:
23. Other serious illness or disabling condition No Yes What/when?
24. Was your last menstrual period more than 3 weeks ago? No Yes How many weeks?
25. Are you currently breast feeding? No Yes
26. Do you suffer from anxiety, depression or emotional disorders? No Yes
27. Do you drink alcohol? No Yes How much a day?
28. Do you have any allergies (drugs/food/tapes)? No Yes To what?
CURRENT MEDICATIONS TAKEN: Regular & prn. Include ALL medications including over the counter
medications, inhalers, topical, eyedrops & painkillers. Please bring them to hospital with you.
Name Strength How many tablets per day? (number at each time)
A)
B)
C)
D)
E)
YOUR ANAESTHETIC HISTORY (This point forward to be completed by Hospital Staff Only)
30. Have you had a cough/cold/sore throat in the past
No Yes
fortnight?
31. Have you had any problems with anaesthetics or surgery Give details:
No Yes
before (eg. nausea, temperature, and prolonged drowsiness)?
32. Do you have any blood relatives who have had problems Give details:
No Yes
with anaesthetics?
33. Do you have any capped, false or loose teeth? No Yes Give details:
34. Is there any limitation in the movement of your neck or Give details:
jaw? (you should be able to open your mouth at least 2 finger No Yes
widths & be able to tilt your head to look straight up)
35. Does any condition prevent you from undertaking normal What/when?
No Yes
daily activities?
36. Do you have any other chronic pain conditions? No Yes Give details:
37. Tick the box most applicable to you Comments:
A) No limitation to activity
B) Slight limitation to activity, can walk one flight of
stairs without resting
C) Marked limitation of normal activity, cannot walk one
flight of stairs without resting
D) Pain or short of breath at rest
38. Do you have any questions or concerns about the
anaesthetic, operation or coming into hospital you No Yes
would like to discuss?
ANAESTHETIC REFERRAL BY NURSE
Day Surgery Day of Surgery Adm. Refer to Anaesthetist Surgery deferred
Reason / Management:
PHYSIOTHERAPY ASSESSMENT (if required)
Medical & nursing assessment noted Other notes/alerts:
Auscultation:
Muscle power/ROM:
Other specific tests/findings:
Exercise tolerance:
History DVT/PE TED - Size: SEQUENTIAL COMPRESSION - Size:
Instructions given: Deep breathing Supported Huff Circulation Exercises
Specific Instructions:
Physiotherapist Name: Signature: Date:
PLANNING FOR YOUR CARE (refer to nursing guidelines if answer is Yes)
Accommodation House/Unit Nursing Home Hostel Retirement Village Boarding
Number of stairs/steps Front/back: Internal:
A) Will the patient’s occupation affect their recovery? No Yes
B) Will you be by yourself at home when you leave hospital? No Yes
C) Do you have dependants living with you? No Yes
C) If you have dependants, do you have any problems making
No Yes
arrangements to care for them?
D) Do you receive any community support services such as domiciliary Which?
No Yes
nursing, home help, and meals on wheels or ambulance?
E) Do you have any difficulty managing day to day activities such as Which?
No Yes
stairs, bathing, dressing, going to the toilet or performing home duties?
F) Have you had any falls in the last few months? No Yes
F) Do you use a walking aid such as a stick or frame? No Yes
G) Do you have any swallowing/eating difficulties or special dietary
No Yes
needs?
G) Have you had a recent change in your weight? No Yes
H) Have you any problems with passing urine or with your bowels? No Yes
I) Have any communication difficulties been identified? No Yes
J) Have any chronic conditions been identified? No Yes
OBSERVATIONS (guidelines 39 – 42) Weight: Height: BMI: Pulse:
B/P: Temp: Resps: Oxygen Saturation:
K) Skin/Integument: does the patient have any wounds,
ulcers, cuts bruises or other problems?
Circle affected areas and describe:
Pressure area risk score:
PRE-ADMISSION PLAN
Discharge problems identified? No Yes
Education sheet discussed with patient Post op pain education performed
Patient care plan completed? No Yes Vital signs recorded
Nursing assessment completed by:
Nurse’s name: Signature/designation: Date:
Patient’s signature: Expected Discharge Date:
