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Lokalt vårdprogram

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AKTUALISERING<br />

Till: ______________________________________ Faxnr: ____________________<br />

Från: _____________________________________ Datum: ___________________<br />

Angående patient<br />

Namn: _________________________________ Personnr: _________________________<br />

Adress: ____________________________________________________<br />

____________________________________________________<br />

Tele: ____________________________<br />

Närmast anhörig / närstående: __________________________________________________<br />

Tele: ______________________________________________________________________<br />

Samtycke till information enligt nedan mellan specalistmottagning, primärvård och<br />

biståndshandläggare i kommunen.<br />

Patient JA NEJ<br />

Anhörig JA NEJ<br />

Underskrift: ……………………………………………………………………….<br />

Demensutredning pågår<br />

Demensdiagnos ja<br />

Ansvarig läkare: _____________________________________________<br />

Patientens/anhöriges önskemål:<br />

________________________________________________________________<br />

________________________________________________________________<br />

________________________________________________________________<br />

________________________________________________________________<br />

___________________________________________________________________________<br />

Genombrottsprojektet 2005<br />

Minnesmottagningen/PV/Kristianstads kommun<br />

46

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