Example of ambulation plan

PATIENT DETAILS
Patient name:
Address	Hospital Number: Date of Birth: NHS Number: Sex:
Phone No:	GP:

REQUEST DETAILS
Category	Creation Date
Date of referral:	Referral Ward/Department:
Requester:
Contact No:	Bleep:
Clinical Lead:	Priority:	-- Select --
Clinical details

Relevant Results:	Creation Date
Date of referral:	Current Antibiotic Therapy (dose & frequency):
Pending results/dates expected:	Allergies:
	Duration of treatment:   Provisional stop date:   Previous Antibiotic Therapy

COVID-19 SWAB
Patient COVID-19 Swab taken	Yes No
Accompanying Parent COVID-19 Swab taken:	Yes No

Any child protection concerns?	Yes No
Details:

Access to telephone?	Yes No
Telephone number:

Can provide transport to return?	Yes No
IV Access:	Peripheral Cannula PICC Hickman Portacath
Safety netting advice sheet given:	Yes No

Plan (if positive results/investigation):