SPOT-ON Data Capture Form - General Practice

All forms to be sent to SPOT-ON secure Medical Objects address (OS45600003L)

Date:  <TodaysDate>           Time:  <CurrentTime>

Consent

Does the patient consent to involvement in SPOTON trial <Does the patient consent to involvement in SPOTON study?>
Does the patient consent to follow up short telephone interview?<Does the pt consent to follow up short phone interview?>

Patient Demographics
Re: <PtFirstName> <PtSurname> 
DOB: <PtDoB>          Age: <PtAge>             Sex: <PtSex>
Medicare Number: <PtMCNo>
DVA Number (if applicable): <PtDVANo>
Address: <PtAddress>
Telephone: <PtPhoneH>     <PtPhoneMob>
Ethnicity: <PtEthnicity>

GP details
<DrName>           Provider Number: <DrProviderNo>
<DrAddress>

Arrival Details
Mode of arrival:  <Mode of arrival>

Clinical Details
Provisional diagnosis:  <Provisional diagnosis>
Diagnositic category: <Diagnostic category (can select multiple)>
Clinical Care Pathway used (if any): <Clinical Care Pathway decision tool used (if any)>
Consumables used: <Consumables used (can select multiple)>
Other consumables: <Any other consumables?>

Length of consultation with GP: <Length of consultation with GP>
Length of time with nurse: <Length of time with nurse>
If greater than 60 minutes with nurse, give time: <If greater than 60 minutes with nurse, give time>
Medicare items billed: <Medicare items billed:>
Final outcome: <Final outcome>
Final outcome other: <Final outcome, other - please state>

TRANSFER OF CARE - TO PATIENT'S REGULAR GP OR TO EMERGENCY DEPARTMENT

Dear Doctor, 
Thank you for seeing <PtFullName> , aged <PtAge>, for further management of their condition as described above.

Additional hand-over information to usual GP: <Addition hand-over information to usual GP (if any):>
Reason for referral on to DEM:  <Reason for referral on to DEM (if applicable)>

PHOTOCOPY THIS FORM FOR PATIENT TO TAKE TO USUAL GP OR EMERGENCY DEPARTMENT
<Photocopy this form for pt to take to usual GP or DEM>