REF-2041·Drafted just now
Eileen Hargreaves — Pre-admission summary
Drafted from 3 source documents · Royal Preston Hospital
AI-assisted draft — not a clinical record.
This summary was generated from uploaded documents to save typing time. A registered manager or senior carer must read every section, check it against the source documents, and sign off before it is used to make an admission decision.
Complete· 5
Needs clarification· 4
Missing information· 1
Manager review required· 3
Resident overview
Source: Discharge summary, GP letter
Complete
- Name
- Eileen Margaret Hargreaves
- Date of birth
- 14 March 1941 (age 84)
- NHS number
- 485 777 3456
- Currently at
- Royal Preston Hospital, Ward 12
- Proposed admission
- Permanent residential placement
Reason for referral
Source: Discharge summary, p.1–2
Complete
- Admitted following a fall at home resulting in a fractured left neck of femur. Hemiarthroplasty performed 18 April. Now medically optimised but unable to return home safely due to reduced mobility and increasing cognitive concerns. Family and social worker support move to residential care.
Mobility
Source: Physiotherapy notes, 28 April
Needs clarification
- Transfers
- Requires assistance of one with a frame. Stand-aid trialled on ward.
- Walking
- Short distances (5–10m) with Zimmer frame and supervision of one.
- Falls
- Two falls in last 6 months. Falls risk assessment completed in hospital.
- Clarify whether stand-aid is needed long-term or only during recovery period.
Personal care needs
Complete
- Washing
- Full assistance of one with strip wash at bedside.
- Dressing
- Assistance of one. Prefers dresses and cardigans.
- Toileting
- Uses commode at night, assisted to toilet by day.
Cognition and memory
Source: GP letter, ward observations
Manager review required
- Working diagnosis of mild-to-moderate vascular dementia (GP letter, March). 4AT score on admission: 3. Episodes of disorientation reported overnight on the ward.
- No formal memory clinic assessment on file. Manager to confirm placement category (residential vs. residential dementia) before accepting.
Medication notes
Source: Pharmacy discharge list, 2 May
Needs clarification
- Apixaban
- 2.5mg BD — anticoagulant, post-op cover.
- Amlodipine
- 5mg OD.
- Atorvastatin
- 20mg ON.
- Paracetamol
- 1g QDS PRN.
- Confirm review date for apixaban and whether covert administration has ever been considered.
Nutrition and swallowing
Complete
- Diet
- Normal consistency. No SALT involvement.
- Fluids
- Thin fluids. Encouragement required.
- MUST score
- 1 — low risk, monitor weekly.
- Preferences
- Dislikes fish. Enjoys milky tea and porridge.
Continence
Needs clarification
- Daytime
- Continent with prompting and timed toileting.
- Night-time
- Wears pads. Occasional episodes of incontinence.
- Confirm preferred pad type and supplier on admission.
Behaviour or emotional wellbeing
Manager review required
- Mostly settled and sociable. Ward staff describe occasional verbal agitation in the evenings (sundowning pattern). No physical aggression recorded.
- Low mood noted since husband's death (2023). Not currently on antidepressants.
Infection control
Missing information
- MRSA screen
- Negative — 19 April.
- C. diff
- Not screened.
- COVID-19
- Vaccinated, last booster autumn 2025.
- Missing: current CPE screening result. Required before transfer per local protocol.
Family / contact details
Complete
- Daughter (NOK)
- Claire Hargreaves — 07700 900221 — visits weekly, holds LPA Health & Welfare.
- Son
- David Hargreaves — 07700 900118 — lives in Glasgow.
- GP
- Dr A. Mehta, Fulwood Surgery, 01772 700 000.
Key risks to review
Manager review required
- Falls risk — recent fracture, reduced mobility, possible night-time disorientation.
- Anticoagulation — bleeding/bruising risk; review handling and incident reporting.
- Cognitive decline — capacity to consent to admission not formally assessed.
- Skin integrity — Waterlow 16, currently intact; monitor sacrum and heels.
Questions to ask before accepting admission
Needs clarification
- Has a mental capacity assessment been completed for the move into care?
- Is a DoLS application anticipated, and who will submit it?
- Confirm funding pathway — CHC checklist outcome and LA contribution.
- Latest CPE / MRSA screening results within the last 7 days?
- Any equipment (stand-aid, pressure mattress) being transferred with resident?
Manager review & decision
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