Information
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Document No.
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Conducted on
Stage 1 - Critical information
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Hello, focus on call, this is...
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Activate time stamp of call
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What is the reason for this call?
- Cat 1 incident
- Cat 2 incident
- Client health related
- Emergency maintenance
- Medication related
- Provision of general information
- Seeking information / authorisation
- Staffing related
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Is this a life threatening situation?
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Have emergency services been contacted?
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If yes, which departments?
- Victoria Police
- MFB / CFA
- SES
- Ambulance
- Poisons Information
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What time did you call the emergency services?
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Have emergency services responded?
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If yes, what time did they arrive?
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Do you require further on site support?
Stage 2 - Incident information
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Client(s) involved
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Location of incident
- Ash Flat
- Ash House
- Balcombe
- Banksia
- Berry Flat
- Berry House
- Bondi
- Bungower
- Cedar Flat
- Cedar House
- Century
- In Community
- Hartigan
- Maysbury
- Oak Flat
- Oak House
- Olsen
- Oppy
- Outreach
- Pine
- Seaview
- The Rise
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Cat 1 or Cat 2 incident - What type?
- Absconding
- Physical Assault
- Property Damage
- Self Harm
- Sexually inappropriate
- Verbal Abuse
- Fire
- Death (client)
- Death (employee)
- Other
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Client health related - What type?
- Injury
- Hospitalisation
- Missing
- Seizure
- Illness
- Diabetes
- Deterioration of known condition
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Emergency maintenance - What type?
- Building damage
- Water outage
- Power outage
- Gas leak
- Electricity hazard
- Flooding / storm damage
- Uncontrolled animal
- Vehicle breakdown
- Appliance malfunction
- Fallen trees
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Medication related - What type?
- PRN request
- PRN no effect
- PRN missing
- Emergency insulin
- Error - Family
- Error - Incorrect client
- Error - Incorrect dose
- Error - Missed dose
- Error - Client refusal
- Error - Spilt medication
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Staffing related - What type?
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Provision of general information? Provide details...
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Staff member seeking information? Provide details...
Stage 3 - Response to caller
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Type of response
- Allocated extra staff
- Authorised PRN administration
- Contacted emergency services
- Denied PRN administration
- Recorded general information
- Supplied adequate information
- Denied request for extra staff
- Referred to emergency services
- Non-emergency
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Provide details of response
Stage 4 - Post call actions
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On call receiver - Signature
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On call receiver - Verify time and date