Checklist for contact of General Practitioner (GP) or RACF acute care Support Service (RaSS)

This information does not replace clinical judgement. Refer to Conditions of use and copyright for further T&Cs.

An effective clinical handover of information from the RACF clinician to the GP or RaSS team can result in:

  • Improved resident safety
  • Improved co-ordination of resident care
  • Supports effective transition of professional responsibility and accountability for care

If the resident has unstable vital signs, refer to the Management of a resident with unstable vital signs pathway

Checklist

Step 1

Collect resident’s medical record and medication chart including:

  • Results of recent tests
  • Recent changes to medications
  • Substitute health decision maker contact details e.g. enduring power of attorney (EPOA) contact details
  • Contact details for treating GP

Step 2

Have a copy of the relevant RACF decision support tool in front of you

Step 3

Check the resident’s Advance Health Directive (AHD) / Acute Resuscitation Plan (ARP) / Advance Care Plan (ACP) for documented wishes

Step 4

Undertake a full set of vital signs including:

  • Response and cognition
  • Airway and breathing assessment (respiratory rate and effort; oxygen saturations)
  • Circulation assessment (pulse and blood pressure)
  • Disability assessment (including blood glucose)
  • Temperature and pain assessment (use cognition appropriate tool)

Step 5

Pen and paper available to document any instructions

Step 6

Prepare to discuss with GP or a RaSS in the ISBAR format
Identify yourself, your role and where you are calling from
Situation or the reason for your call and the current problem e.g. Chest pain
Background including past medical history of resident and usual level of function
Assessment including

  • Vital signs
  • Other relevant clinical findings including any recent behavioural changes
  • Confirmation of resident choices
  • Recent medication changes
  • Recent investigation results

Recommendations arrived at in collaboration with GP or a RaSS

Step 7

If resident is to be reviewed in facility by GP or a RaSS or to be transferred to hospital – prepare documentation including copies of:

  • Facility name and 24 hour contact details for RN or clinical manager
  • Summary of reason for transfer and recent vital signs
  • Past medical history and baseline level of function
  • Recent medical notes, results of investigations
  • Recent changes to medications
  • Current (regular, prn and short-course) medication AND sign-off charts
  • Advance Health Directive or Acute Resuscitation Plan or Advance Care Plan
  • Contact details for next of kin and substitute health decision makers

Step 8

Where resident lacks capacity or consents, notify next of kin / substitute health decision maker of resident condition and ensure they are involved in care planning

Checklist

Click this link to view the full checklist.

Health professionals should always remain within their scope of practice; these pathways should never replace clinical judgement.

Last updated: 20 April 2022