Re: <PtFirstName> <PtSurname>   DOB: <PtDoB>

Sunshine Coast Hospital & Health Service

URGENT: COVID escalation of care
Send via secure messaging:
Medical Objects:  NQ45600007J
Healthlink: qldnghop

PATIENT'S DEMOGRAPHIC DETAILS
Title: <PtTitle>
First name: <PtFirstName>
Preferred name: <PtPrefName>
Middle name: <PtMidName>
Surname: <PtSurname>
Date of birth: <PtDoB>
Residential address: <PtAddress>
Phone – home: <PtPhoneH>   mobile: <PtPhoneMob>       alternate: 
Medicare number, where eligible: <PtMCNo> / <PtMCLine> Expiry: <PtMCExpiry>
Name of the parent or caregiver, NOK: 
NOK: <NOKName>      relationship: <NOKRelation>
NOK phone: <NOKContact>      alternate: <NOKContact2>
Preferred language: <Preferred language>   interpreter required: <interpreter required>
Identifies as Aboriginal and/or Torres Strait Islander: <Aboriginal and/or Torres Strait Islander Status>

PRACTITIONER DETAILS
Full name: <DrName>
Full address: <DrAddress>
Phone: <DrPhone>   Fax: <DrFax>   Email: <DrEmail>
Provider number: <DrProviderNo>
Date of request: <TodaysDate>

COVID-19 HISTORY
Date of positive test: <Date of positive COVID-19 test>
Type of test: <Type of test>
Date of first symptoms: <Date of first symptoms>
COVID-19 vaccination status: <COVID-19 vaccination status?>
Reason test could not be performed (if applicable): <Reason test could not be performed (if applicable)>
 
RELEVANT CLINICAL INFORMATION
Current symptoms: <Current symptoms>
Reason for escalation of care: <Reason for escalating care>
Medical risk factors: <Medical risk factors>
Social risk factors: <Social risk factors>

STANDARD CLINICAL INFORMATION
Allergies: 
<Reactions>

Past Medical history: 
<SelectedPMH>

Current medications:
<SelectedRx>

Immunisations:
<Imm>