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High Risk Medical Activity Application and Declaration
1
2
High Risk Medical Activity Application and Declaration
Parent/Guardian
(Required)
First Name
Last Name
Email
(Required)
Educator
(Required)
First Name
Last Name
Email
(Required)
Child
(Required)
First Name
Last Name
Submitted By
(Required)
Medical Activity
(Required)
PEG
Gastrostomy (G-tube)
Nasogastric (NG-tube)
Other
Please describe if you selected "Other"
(Required)
Documentation
1. The current ALHCA Medical Conditions Plan and offical Medical Management Plan has been received, reviewed and understood by the Educator?
(Required)
Yes
No
2. Does the Educator understand when and how to escalate concerns?
(Required)
Yes
No
3. Have all required child-specific documents, consent forms and medication authorisations been received by the Educator and the Service before care commenced?
(Required)
Yes
No
Please upload the Medical Management Plan written by the treating health practitioner
(Required)
Max. file size: 256 MB.
Training and Competency
4. Has the Educator completed child-specific practical training provided by the treating health professional?
(Required)
*Please note, you can only successfully complete this form if the Educator has had practical training by the treating health professional
Yes
No
5. Has the treating health professional provided clinical guidance and training?
(Required)
Yes
No
6. Does the Educator feel competent to administer the high risk medical activity successfully?
(Required)
Yes
No
Date training was completed
(Required)
DD slash MM slash YYYY
Please upload proof of training/assessment from health practitioner
(Required)
Max. file size: 256 MB.
Child-Specific Knowledge
7. Can the Educator identify the child's individual feeding schedule, equipment requirements and any documented care considerations by referring to the child's Medical Condition Plan or other documentation provided by the treating health professional?
(Required)
Yes
No
8. Has the Educator completed an orientation with the Family, including the child's routine, equipment location, emergency equipment and communication expectations?
(Required)
Yes
No
Equipment
9. Before each session of care, does the Educator confirm that all required equipment, consumables and the child's emergency bag are available and ready for use?
(Required)
Yes
No
10. Does the Educator understand the process for reporting damaged, missing or faulty equipment before care continues?
(Required)
Yes
No
Monitoring and Communication
11. Does the Educator understand their responsibility to observe the child's wellbeing throughout the session of care and report any changes promptly?
(Required)
Yes
No
12. Does the Educator understand that any concerns, unexpected events or incidents must be documented and reported in accordance with ALHCA's policies and procedures?
(Required)
Yes
No
Escalation
13. Can the Educator identify situations requiring immediate escalation, including following the child's Medical Conditions Plan, Medical Management Plan, Emergency Plan and contacting the Family and emergency services where required?
(Required)
Yes
No
14. Does the Educator understand that they must not make clinical decisions or alter feeding, medications or care arrangements unless supported by updated clinical documentation?
(Required)
Yes
No
Approval
The Educator and Family acknowledge that they have read and understood the High Risk Medical Activity Manual and confirm that all required child-specific documentation, training and competency requirements have been provided to Australia's Leading Home Care Agency. They understand that care involving the high risk medical activity must not commence until all documentation has been reviewed and written approval has been provided by the Service.
(Required)
Yes
No
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