Consider referral for medication review by GP or Pharmacist OR add MARS sheet 7. Bowel Habit Action Daily Yes No If bowel problems complete 14 day food, stool and medication diary Alternate days Yes No Less Yes No Faecal incontinence Yes No Please refer to the Bristol Stool Chart Does resident have Yes No awareness of the need to open bowels? Consistency of 8. Contributory Factors Action Memory impaired Yes No Change in behaviour observed? Awareness of needing to pass Yes No Independently mobile to the Yes No toilet If yes how many carers? Mobile with carer Yes No Mobile with aid Yes No State Aid used: Mobile with aid and carer Yes No Please state any adaptions used Ability to hold a utensil and Yes No drink unaided Can manage clothes quickly Yes No Consider Velcro on clothing Name number…………………………………. Date of Birth…………… ……………………….NHS SECTION 9 & 10 TO BE COMPLETED BY NURSING HOMES ONLY AND MUST BE SIGNED BY A REGISTERED NURSE (or if a Healthcare Assistant completes the form then a Registered Nurse MUST countersign)
Consider referral for medication review by GP or Pharmacist OR add MARS sheet 7. Bowel Habit Action Daily Yes No If bowel problems complete 14 day food, stool and medication diary Alternate days Yes No Less Yes No Faecal incontinence Yes No Please refer to the Bristol Stool Chart Does resident have awareness of the need to open bowels? Yes No Consistency of 8. Contributory Factors Action Memory impaired Yes No Change in behaviour observed? If yes how many carers? Awareness of needing to pass Yes No Independently mobile to the toilet Yes No Mobile with carer Yes No Mobile with aid Yes No State Aid used: Mobile with aid and carer Yes No Please state any adaptions used Ability to hold a utensil and drink unaided Yes No Can manage clothes quickly Yes No Consider Velcro on clothing Name ……………………….NHS number…………………………………. Date of Birth…………… SECTION 9 & 10 TO BE COMPLETED BY NURSING HOMES ONLY AND MUST BE SIGNED BY A REGISTERED NURSE (or if a Healthcare Assistant completes the form then a Registered Nurse MUST countersign)