FOLLOW-UP

Nurse review

Nurse Cathy entered all information gathered in the work-up above and entered it into each patient's AGEDAT-G1 record

Dr Review

It was Dr. Murphy's long standing arrangement to regularly attend each nursing home once every week.

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Utilising the routine weekly scheduled visits, and basing the required actions on a review of the information gathered in the initial work-up, it took 2 months for Dr. Murphy to complete the AGEDAT-G1 record for each of the 12 patients.

This included :

• Reviewing the work-up data collected for each patient and

• Performing the required portions of the Physical Examination

• Performing a Medication Review for each patient

• Request nursing home staff obtain

  • Further laboratory blood tests for 2 patients arising from physical examination findings and review of initial work-up lab. results

  • CXR for 4 patients

  • Barthel Index scoring for 8 patients whose Edmonton scale score indicated moderate or severe Frailty

  • Frequency and Volume chart for 1 female patient who complained of increased frequency in the absence of a UTI

  • International Prostate Symptom Score (IPSS) for 1 male patient who reported increased nocturnal voiding in the absence of a UTI

  • Epworth Sleepiness scale for 2 patients who staff reported as being unusually sleepy and snoring loudly in recent weeks

  • Advance Care Plan Statement from 3 patients able to comply

  • DNACPR document signed by relatives of 2 demented patients, where no such record was found to be held by the nursing home

• Request Nurse Cathy attend the nursing home to perform

  • QFracture score for 3 patients whose FRAX score was in the low bone mass range

  • DOLOPLUS-2 scale assessment for 1 patient because of poorly controlled pain and dementia

  • MoCA evaluation for 2 patients whose mental status had markedly deteriorated in recent months

• Referral of

  • 2 patients to dietician because of low BMI, and 1 because of high BMI

  • 3 patients to podiatrist

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Nurse visits

2 Domiciliary visits were required for Nurse Cathy to perform the

• 3 Q-Fracture score calculations requested by Dr Murphy

• 1 DOLOPLUS-2 scale assessment requested by Dr Murphy

• 1 MoCA evaluation

which were requested by Dr Murphy

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Patient allocation to appropriate register

scheduled appointments as required by each register's protocol

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Dr. completion of AGEDAT-G1 record

Utilising the routine weekly scheduled visits, it took 1 month for Dr. Murphy to

• Process the results of the various tests he had requested be performed by the Nursing Home Staff and by Nurse Cathy,

• Prescribe appropiate medication

• Refer x patients along the way

  • 1 to Psychiatrist (re-evaluation of dementia medication)

  • 1 to ENT surgeon (investigation of excessive snoring)

  • 1 to Urologist (suspected residual volume and/or bladder pathology)

• Update the AGEDAT-G1 record for each of the 12 patients accordingly