GP intervention request

Important: For nursing and care home use only

All nursing and care home staff are able to submit a GP intervention request form on behalf of their residents, who are registered patients of Grove Surgery.

Requests must be submitted before 10am.

If you are a patient or need to contact us directly, you can phone us on 01842 752285.

GP Intervention Request

Please ensure all requests are received before 10:00. Coordinate all interventions with one point of contact for GP surgery to call.

Care Home:

Room Number:

Section

Coordinator Name:

About the Patient’s Problem

Please tell us about the problem. If the practice is already aware of this problem, please tell us what has changed:

How long has this been a problem?

Observations:

Readings

Please provide the readings below.

Systolic “Higher”

Diastolic “Lower”

Pulse

Sats

Temperature

Blood Glucose

Respiratory Rate

Other Details

Sputum Colour:

Urinalysis:

Is the patient coughing or chesty?

Yes

Please specify if the condition is acute or chronic:

Acute

Chronic

Further Information:

How would you like us to deal with the problem?

Telephone

Appointment

Visit

Completed By

Your Name:

Your Position:

Date:

Time: