TRANSITION CHECKLIST Q & A : Your help is needed to provide Remarkable Care!

1.Why is it necessary to document the patient’s current ADLS, mental status, medical/surgical history and immunization status?

  • Current ADLS function assists us to maintain the patient’s current functional status. ADLS include bathing, dressing, and toileting, transferring, continent and feeding. Please document if the patient is independent, with assist, or dependent and type of assistive device (walker, cane).
  • Mentation – Mental status baseline assists us to determine changes in behavior and or level of consciousness. A change in baseline mental status is a feature of delirium. Delirium can be caused by infection (i.e. urinary tract infection, pneumonia, electrolyte imbalance, adverse drug reaction, dehydration). Info helps to identify a potential increase in needs, supports and services within the patients living environment.
  • Medical and Surgical History – to help with decisions, diagnosis i.e.determination of abdominal pain
  • Immunization status – to help with decisions, diagnosis and prevent unnecessary vaccination.

2. Why is it necessary to send the current medication list (MAR) with doses and last time dose administered?

  • Current MAR with doses and documentation of times allows assessment of potential meds that be contributing to presentation; gives an overview of any new meds that have been added, or changed. Correct information assists with review of adverse drug reactions or drug-to-drug interactions especially if patient presents with mental status changes. Recent antibiotic use (past 30 days) along with condition being treated along with approximate time of last dose and amounthelp promote antibiotic stewardship.

3.Why is it necessary to document if the fall history was witnessed, loss of consciousness, and head injury, along with the mechanism of the fall i.e. trip and fall over an object or was this due to syncopal episode?

  • Accuracy of fall history is necessary to determine the plan of care, facilitate necessary and or avoid unnecessary exams and tests and determine eligibility for skilled home care services.

4. How can other documents such as recent orders, progress notes, lab or radiology exams assist with care of the patient going to the ER?

  • Additional information may help differentiate diagnosis, determine plan of care, and may reduce unnecessary exams/tests.

5.Nutrition info is important to prevent aspiration and assists us if patient takes meds with applesauce etc.

6.Why is it necessary to let us know the family member has been contacted and if they are coming?

  • This helps facilitate patient safety because the resident's family members know them better than us.

7.Why is the resuscitation status (code status) required along with the signed document?

  • This helps prevent wrongful resuscitation and we have a legal document to honor – this is also important for EMS since they are the interim care provider during transport.

8.Why use the transition checklist?

  • Checklists have proven to aid in recall

You play an important role in your residents “hand-over” of care. A safe hand-over ensures patient safety.