DOC

RESIDENTIAL Care Services Monthly Update CLAIMS CALL CENTRE FAX

By Janet Greene,2014-05-12 21:20
11 views 0
RESIDENTIAL Care Services Monthly Update CLAIMS CALL CENTRE FAX

    RESIDENTIAL CARE SERVICES

    MONTHLY UPDATE

CLAIMS CALL CENTRE FAX MAIL

    Phone 604 231-8888 604 233-9777 WorkSafeBC

    Toll-free 1 888 967-5377 Toll-free 1 888 922-8807 PO Box 4700 Stn Terminal

     Vancouver BC V6B 1J1

    1. Worker information

    Worker last name First name Middle initial WorkSafeBC claim number

Address line 1 Address line 2

    City Province/State Country (if not Canada) Postal code/Zip

Phone number (please include area code) Extension Birthdate (yyyy-mm-dd)

2. Provider information

    Provider/company name

Address line 1 Address line 2

    City Province/State Country (if not Canada) Postal code/Zip

Phone number (please include area code) Extension Fax number (please include area code)

    Contact name Contact phone number (please include area code)

    3. Mental status and behaviour Improved Declined No change Orientation Mood Ambulatory time

    Alert Anxious Up most of day

    Oriented to person Agitated Bed rest

    Oriented to place Verbally abusive Sleeps more than 812 hours

    Oriented to time Withdrawn Up for short periods

    Confused at times Diagnosed depression Up 13 times per week

    Up 47 times per week Normal mood

    4. Nutrition and hydration Improved Declined No change Food preparation and feeding Appearance Nutrition

    Prepared by staff Weight loss Balanced diet

    Prepares meals by self Weight gain Unbalanced

    Prepares snacks by self Emaciated Inadequate intake

    Feeds self Underweight Grocery shops regularly

    Feeds self with splint Normal Rarely shops 83D34 Workers’ Compensation Board of B.C. (R09/08) Page 1 of 3

    Residential Care Services Monthly Update

     (continued)

    Worker last name First name Middle initial WorkSafeBC claim number

    Fed by staff Overweight Primarily take-out food

     Obese

    5. Continence Improved Declined No change Bladder Urinary tract infection Bowels

    Intermittent catheterization Symptomatic UTI Continent Catheter indwelling Urine for C&S sent Toilet upon desire Catheter irrigation Antibiotics prescribed Partial incontinence

     (times per week: ) Condom catheter drainage Adequate fluid intake

    Constipation Inadequate fluid intake

    Diarrhea

    Hemorrhoids

    Bowel routine 6. Skin care Improved Declined No change Skin assessment Location #1

    Skin intact

    New pressure area Size Stage Pre-existing pressure area w , l , d Other:

    Odour Drainage Regular turn schedule

     Regular weight shifts while up

    Concerns Location #2

    Size Stage

    w , l , d

    Odour Drainage

    Treatment

    7. Psychosocial Improved Declined No change Family living nearby No social relationships Goes out occasionally Family supportive Staff interaction only Goes out to medical

     appointments only Family does not live nearby Goes out regularly

    Rarely leaves home Good support system Goes out with staff only

    Housebound Poor support system Goes out with family and friends

    8. Concerns or comments

    83D34 (R09/08) Page 2 of 3

    Residential Care Services Monthly Update

     (continued)

    Worker last name First name Middle initial WorkSafeBC claim number

9. Number of nursing visits

    Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

     Time Day 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

     Time

Signature Date (yyyy-mm-dd)

Personal information on this form is collected for the purposes of administering a worker’s compensation claim by WorkSafeBC in accordance with the Workers Compensation Act and the Freedom of Information and Protection of Privacy Act. For further information about the collection of personal information, please contact WorkSafeBC’s Freedom of Information Coordinator at PO Box 2310 Stn Terminal, Vancouver BC, V6B 3W5, or telephone 604 279-8171.

    83D34 (R09/08) Page 3 of 3

Report this document

For any questions or suggestions please email
cust-service@docsford.com