INTERACT-Hospital_to_Post_Acute_Care_Transfer_Form-June-2018

Hospital to Post-Acute Care Transfer Form V e r s i o n To o l V e r s i o n Too l sentative/Caregiver/ Proxy Contact egiver Name _ A Patient Information B Respresentative/Caregiver/ Proxy Contact _ ) Name Proxy/GuardianDOB Name (if different)/ _ / Gender:  M  F Family/Caregiver Name _ _ ) Language:  English  Other _ Healthcare Proxy/Guardian Name (if different) _ Race/Ethnicity:  White  Black  Hispanic  Other Tel ( _ ) Tel ( _ ) erring Hospital Information C Advance Directives/Goals of Care  Full Code  DNR  DNI (Do Not Intubate) g RN  DNH (Do Not Hospitalize)  No Artificial Feeding  Comfort Care _ )  Hospice Care g MD  Other (specify) _ _ ) Were goals of care discussed during this hospitalization?  No  Yes (specify) mission to Hospital / / Patient decision making capacity?  Capable of making decisions D Transferring Hospital Information Hospital Unit Discharging RN Tel ( _ ) Discharging MD Tel /Page ( ) Date of Admission to Hospital / /  Requires proxy _ ( _ ) E Post-AcuteTel Care Information Transfered to _ Tel ( _ ) Nurse to Nurse verbal report?  No  Yes (specify to whom) _ _ Tel ( _ ) _ F Hospital Physician Care Team Information _ Tel ( _ ) _ Primary Care Physician (or Hospitalist) _ Tel ( _ ) _ _ Tel ( _ ) _ Specialist Specialty Tel ( _ ) _ Specialist Specialty Tel ( _ ) _  N/A _ G Pain KeySite Clinical Information O2Signs Sat Weight Vital Time Taken _ Pain Rating  N/A Pain Site _ riented, cannot follow commands  Not Alert Temp BP HR _ RR _ O2 Sat Weight _ Mental Status  Alert  Disoriented, follows commands  Disoriented, cannot follow commands  Not Alert Diagnoses Primary Discharge Diagnosis Other Medical Diagnoses Mental Health Diagnoses H High Risk Conditions/Treatment Information (check all that apply) _ / /  Fall  EF _ % DryPrecautions: Weight (if known) Risk  Low EF  Heart  Other _ Failure:  New diagonsis?  Exacerbation this admission? Date of last echo / /  EF _ % Dry Weight (if known)  -3 days  Other _  Anticoagulated: Reason:  Afib  DVT/PE  Mech Valve  Specific Dx: Duration Goal INR: Date started /Indication(s): _ / _  On PPI:  In-hospital prophylaxis and can be d/c  Post-OP  Low EF  Other _  1.5 -2.5  -3  Other _  Specific Dx: Time (am/pm) _  On Antibiotics: Indication(s): Total Treatment Course days Date started / _ / _ On Scheduled Insulin Most  Yes  No  Diabetic: recent glucose Time (am/pm) _ Date / _ / _ (Please attach list of recent values if available) On Scheduled Insulin  Yes  No Medications and Allergies Medication List I Attached Procedures & Key Findings (during this hospitalization) * Please Attach Reports * ase provide a HARD COPY PRESCRIPTION FOR CONTROLLED SUBSTANCES List Procedures (surgeries, imaging) J Medications and Allergies ergies:  None known  Yes (specify) _ Please provide a HARD COPY PRESCRIPTION FOR CONTROLLED SUBSTANCES n med:  No _  Yes (specify) Allergies:  None known  Yes (specify) Dose Key _ findings Pain med:  No  Yes (specify)  Medication List Attached Last Dose (am/pm) _ Dose _ _ Last Dose (am/pm) resold or incorporated in software without permission of Florida Atlantic University © 2014 Florida Atlantic University, all rights reserved This document is available for clinical use, but may not be resold or incorporated in software without permission of Florida Atlantic University ©2014 Florida Atlantic University, all rights reserved This document is available for clinical use, but may not be resold or incorporated in software without permission of Florida Atlantic University Updated June 2018 Transfer Form (cont’d) Hospital Post-Acute CareCare ospital toto Post-Acute Care Hospital to Post-Acute Acute Care Transfer Form (cont’ ) d) ransfer Form (cont’ d) d Form (cont’ nt’ d ) Transfer V K Nursing Care Physical and Sensory Function K Nursing rsing Care Care K Nursing Care Ambulation  Independent  With Assistance  With Assistive Device Weight Bearing  Full  Partial L / R  None L / R Transfer Sensory Function  Self  1-Person Assist V e r s i o n To o l Sight:  Normal  Impaired  Blind Devices  Wheelchair  Walker  Not Amb o nTo 4o.0l eToo V er sV i oenr s4i.0 r s ilo n Too l  2-PersonVAssist Hearing:  Normal  Impaired  Deaf  Cane  Crutches  Prosthesis  Glasses  Contacts  Dentures Physical and Sensory Function al and Sensory Function Physical and Sensory Function Hearing Aid L / R Ambulation Ambulation  Independent  Independent Independent WithAssistance With Assistance  With Assistive Device  Not Ambulatory ation  With Assistive Device  Not Ambulatory With Assistance  With Assistive Device  Not Ambulatory  With Assistance  With Assistive Device  Not Ambulatory for catheter:  Retention Continence  Catheter Date inserted / / _  Partial R Partial  None tWeight BearingBearingWeight Bearing Full  Full  Partial L / R L / Reason L / R L / RBladder  Full L / R None None Incontinent L/R  Partial L / R  None L / R Bowel Incontinent Skin protection  Other (specify) Transfer  1-Person  2-Person er  Self  Self  1-Person Assist Assist  2-Person Assist Assist Transfer  Self 1-Person Assist 2-Person Assist  1-Person Assist  2-Person Assist  Ostomy  Date of last BM / / Sensory Function Sight:  Normal  Impaired  Blind Hearing:  Normal  Impaired  Deaf y Function Sight:  Normal  Impaired  Blind Hearing:  Normal  Impaired  Deaf Sensory Function Sight:  Normal  Impaired  Blind Hearing:  Normal  Impaired  Deaf ed  Blind Hearing:  Normal  Impaired  Deaf  Wheelchair  Walker  Cane  Crutches  Wheelchair sDevices  Walker  Cane  Crutches  Wheelchair Devices  Walker  Cane  Crutches Nutrition and Hydration  Walker  Cane  Crutches  Prosthesis  Glasses Consistency Contacts  Dentures  DenturesFree Water Restriction  Prosthesis  Glasses  Contacts  Dentures  Prosthesis  Glasses  Contacts Diet  Glasses  Contacts  Dentures  Hearing /R  Hearing Aid L Aid / REating L Hearing Aid L / R Instructions  Self  With Assistance  Difficulty Swallowing ( Attach speech therapy recommendations if avai for catheter:  for Retention Continence Bladder Bladder Incontinent (Date Date inserted / ReasonReason for catheter:  Retention ence  Incontinent Bladder Incontinent place Catheter Date inserted / / Tube Feeding G-tube  J-tube Catheter Date inserted / / Free/Water Bolus cc every _ Function Continent Urinary catheter in inserted ) / Reason catheter: Retention Continence Bladder Incontinent  Catheter Date inserted / ntion  Bladder Incontinent  Catheter Date inserted / /  Incontinent Bowel Incontinent  Skin protection  Other (specify) Bowel Monitor Output (describe)  Skin protection  Other (specify) Reasonfor catheter Retention  Tube feed product Rate: cc/h Duration _  Bowel Incontinent  Skin protection  Other (specify)  SkinBowel protection  OtherContinent (specify) Function  Ostomy Ostomy  Date of last BM / /  Incontinent Ostomy  Date of last BM / / TPN Frequency _  Ostomy  Date of last BM / /  Ostomy Date of last bowel movement  Date last BMand / / (ifofknown) Treatments Therapeutic Devices Nutrition and Hydration on and Hydration Nutrition and Hydration  PICC  Portacath Date inserted / / (Please attach imaging report confirming placement ) Diet Consistency Free Water Restriction Consistency Free Water Restriction Diet Consistency Free Water Restriction Cardiac  Pacemaker  ICD  Other (specify) _ nsistency Free Water Restriction Eating Instructions  Self  With Assistance  Difficulty Swallowing ( Attach speech therapy recommendations Instructions  Self  With Assistance  Difficulty Swallowing ( Attach speech therapy recommendations if available) Eating Instructions  Self  With Assistance  Difficulty Swallowing( Attach speech therapy available) Respiratory  CPAP BiPAP recommendations O2if available) _ L ifprn  continuous  Suction  With  Difficulty Swallowing (  Attach speech therapy recommendations if available) TubeAssistance Feeding Tube Feeding  G-tube J-tube Date inserted / / FreeBolus Water Bolus Free cc every hrs eeding  G-tube  J-tube  Date inserted / Free Water ccBolus every hrs  G-tube  J-tube /Date inserted / / Water cc every hrs Date inserted / / Free Water Bolus cc every hrs Therapies (please attach assessment/recommendations) Tube feed product Rate: Duration  Tubefeed product Rate: cc/h Duration h/day h/day  Tube feed product Rate: cc/h cc/h Duration h/day _ h/day  _ PT Rate: cc/h Duration  OT  Speech  Respiratory  Dialysis TPN Frequency TPN Frequency _ TPN Frequency TPN Frequency _ Treatments and Therapeutic ments and Therapeutic Devices Treatments andDevices Therapeutic Devices Skin Care  PICC  Portacath Date inserted / / attach imaging report confirming placement )  Portacath Date inserted / / (Please(Please attach imaging report confirming placement )confirming  PICC  Portacath Date inserted / / (Please attach imaging report placement )  No report skin breakdown / / (Please attach imaging confirming placement )  Pressure ulcer/injury: Stage _ Location _  2nd Pressure ulcer/injury: Stage Location  Pacemaker  Pacemaker  ICD  ICD (specify) Other (specify) _ cCardiac  Pacemaker  Other _ Cardiac  ICD  Other (specify) _ Other wounds (specify) _  ICD  Other (specify) _ Respiratory  BiPAP  O2 _ L O2  prn Lcontinuous Suction  Trach size _ atory  CPAP CPAP  BiPAP  O2 _ L  prn  continuous  Suction  Trach size _ Respiratory  CPAP  BiPAP _  prn  continuous Suction  Trach size _  BiPAP  O2 _ L Risks  prn  continuous  all Suction  Trach size _ and Precautions (check that apply) Therapies attach assessment/recommendations) pies (please(please attach assessment/recommendations) Therapies (please attach assessment/recommendations)  Fall  Delirium  Agitation  Aggression  Unescorted exiting  Aspiration  Other  PT  Speech  Respiratory  Respiratory  Dialysis  Dialysis  OT  OT  Speech  Respiratory  PT  OT  Speech  Dialysis Precautions _  Speech  Respiratory  Dialysis Skin Care are Skin Care Infection Control Issues  Other (specify) _  skin breakdown  Pressure ulcer/injury: Stageulcer/injury: _ Location _  2nd Pressure ulcer/injury: Stage Location _ kinNo breakdown  Pressure ulcer/injury: Stage _ Location _  2nd _ Pressure ulcer/injury: Location _  No skin breakdown  Pressure Stage _ Location  2ndStage Pressure ulcer/injury: Stage Location _ Pressure ulcer/injury: Infection / Colonization  MRSA  VRE  C.difficle  ESBL  Norovirus Location _  2nd Pressure ulcer/injury: Stage Location _ wounds Other wounds er (specify)  (specify) Other wounds (specify) Isolation Precautions  None  Contact  Contact-Plus  Droplet  Airborne _ Risks and Precautions (check that (check apply) all that nd Precautions (check allPrecautions thatall apply) Risks and apply) Immunizations (in hospital)  Influenza:  No  Yes (date): / /  Pneumococcal:  No  Yes (date): /  Fall Delirium Agitation  Agitation    Aggression   Unescorted exiting Aspiration  Aspiration  Other  Delirium Aggression exitingexiting  Aspiration  Other Fall Delirium Agitation Unescorted Aggression  Unescorted  Other Aggression  Unescorted exiting  Aspiration  Other Precautions _ tions _ Precautions _ L Critical Transitional Care Information: Pending Tests and Follow-Up _ Infection Control IssuesControl (specify) Other (specify) _ on Control Issues  Other _ Infection Issues  Other (specify) _ Summarize high-priority care needs for next 24-48 hrs (including essential medications, pain control, tests needed, follow-up): _ Infection / Colonization  MRSA  C.difficle  C.difficle  Norovirus  Norovirus  Flu/respiratory on / Colonization  MRSA  VRE  VRE  C.difficle  ESBL ESBL  Norovirus  Flu/respiratory Infection / Colonization  MRSA  VRE  ESBL  Flu/respiratory VRE  C.difficle  ESBL  Norovirus  Flu/respiratory Isolation Precautions  None  Contact  Contact-Plus  Droplet  Airborne on Precautions  None  Contact  Contact-Plus  Droplet  Airborne Yes No Isolation Precautions  None  Contact  Contact-Plus  Droplet  Airborne Contact  Contact-Plus  Droplet  Airborne Immunizations (in hospital)   Influenza:  Yes (date): / / Pneumococcal:  Yes No (date):  Yes (date): / / nizations (in hospital)  No   Yes (date): /  Pneumococcal:  No  / Immunizations (inInfluenza: hospital)  No Influenza: No / Yes (date): / /  Pneumococcal:  No / Yes (date): / / Yes (date): / /  Pneumococcal:  No  Yes (date): / / Pending Lab and Test Results: L Critical Transitional Care Information: Pending Tests and Follow-Up ical Transitional Care Information: Pending Tests and Follow-Up L Critical Transitional Care Information: Pending Tests and Follow-Up s and Follow-Up Summarize high-priority care for needs nexthrs 24-48 hrs (including essential medications, pain control, tests needed, follow-up): arize high-priority care needs nextfor 24-48 (including essential medications, pain control, tests needed, follow-up): Summarize high-priority care needs for next 24-48 hrs (including essential medications, pain control, tests needed, follow-up): Recommended Follow-Up Tests, Procedures, Appointments: essential medications, pain control, tests needed, follow-up): _ _ _ Pending and Test Results: g Lab andLab Test Results: Pending Lab and Test Results: _ M Attached Document and Notes (check all that are included) _  Admission H&P  Specialist Consultations  Medication Reconciliation  Operative Reports  Diagnost Recommended Follow-Up Tests, Procedures, Appointments: mended Follow-Up Tests, Procedures, Appointments: Recommended Follow-Up Tests, Procedures,  Labs Appointments:  Diabetic Glucose values  PICC placement confirmation  Rehab Therapy Notes  Respirato _  Nutrition Notes  Pain ratings  Code Status  Advance Directive  Discharg _ _ M Attached Document and Notes allare that are included) tached Document and Notes (check(check all that included) M Attached Document and Notes (check all that are included) ncluded) ©2014 Florida Atlantic Univ  Admission  Specialist Consultations  Medication Reconciliation  Operative  Diagnostic mission H&P H&P  Specialist Consultations  Medication Reconciliation  Operative ReportsReports  Diagnostic StudiesStudies  Admission H&P  Specialist Consultations  Medication Reconciliation  Operative Reports  Diagnostic Studies  Medication Reconciliation  Operative Reports  Diagnostic Studies  Diabetic values Glucose  PICC placement confirmation  Rehab Therapy Notes Therapy  Respiratory Therapy Notes Therapy Notes s Labs  Diabetic GlucoseGlucose values  PICC placement confirmation  Rehab Therapy Notes  Respiratory Therapy  Labs  Diabetic values  PICC placement confirmation  Rehab Notes Notes Respiratory  PICC placement confirmation  Rehab Therapy Notes  Respiratory Therapy Notes  Nutrition Pain ratings  Pain ratings  CodeStatus Code Status  Code Status  Advance  Advance Directive  Discharge Summary ition Notes Notes  Pain ratings Directive  Discharge Summary  Nutrition Notes  Advance Directive  Discharge Summary  Code Status  Advance Directive  Discharge Summary © 2014 Florida Atlantic University, all rights reserved This document is available for clinical use, but may not be resold or incorporated in software without permission ofreserved Florida Atlantic University ©2014 Florida all rights reserved ©2014 Florida AtlanticAtlantic University, all rights ©2014University, Florida Atlantic University, all rights reserved Updated June 2018 ©2014 Florida Atlantic University, all rights reserved