Inquiry/ReferralForm
Inquiry Date: Potential Discharge Date:
WasInquirycompletedbyPhoneorVisit?(circle) AttendingPhysician: Short-‐term/Long-‐term(circleone)
Referred by: Contact phone #: _
PAS/OBRAScreenCompleted?Y/Nby: Hospital AdmissionDate:(Inpt/Obs/SwingBed?) Patient Information
Patient: DOB: Sex: M/F Phone:
Homeaddress: City: State: Zip: MaritalStatus: M S D W LivingWill: Y N CodeStatus: FullCode or DNR Patients Present Location: Previous Hospitalization in last 90 days:
ResponsibleParty: POA:Y/N Relationship: Phone: Address:
Howdidyouhearabout us? Previous resident? Y/N Where?
ExpectedPayerSource: SSN#:_ Medicare DaysUsed: WherewereMedicaredaysusedat:_ MCR# Medicarescreen completed? Yes/No
Does Medicaid Application need to befiled? Y/N MCD#:
Insurance: Policy#: Group#: Name ofpolicyholder: Retirementbenefit? Y N Company nameifa retirementbenefit: Other(VA, Workmen’scomp, etc):
Income/Assets: Social Security Benefits$ Pension$
CriminalHistory:Y/Nfor
Circleany ofthefollowingdiagnosis/conditionsapplicable duringhospitalstay: QuadriplegiaMultipleSclerosis CerebralPalsy Hemiplegia/HemipareisSepticemia Dehydration Pneumonia Fever
Vaccinations received: type Infection: type _
Inquirycompleted by:
ClinicalInformation
Diet:
HT:
Cognition: A &O to Person Place Time
TubeFeed: WT:
Other/Describe:
Frequency:
Last14 DaysProcedureOccurrence
Dateif noted
Will
Cont.
Comments
Extensive
Services
Special
Precautions
Clinically
Complex
Special
Equipment
Rehabilitation
Services
Behavioral Risk Triggers
IV/SalineLock Y N IVMeds/PICC Y N Trach/Suction Y N Ventilator Y N CPAP/BIPAP/NebTx Y N Radiation TX Y N
MRSA VRE C-‐Diff Y N Source: Blood Wound Urine
Stool Sputum Nares
Oxygen Y N Chemotherapy Y N G-‐Tube/NG/TPN Y N Transfusion Y N
Ostomy Y N Type:
Dialysis Y N
Bariatric Y N Trapeze Y N Specialty Bed Y N Wound Vac/Supplies Y N
BIPAP/CPAP Y N Rent orOwn?
PhysicalTherapy Y N OccupationalTherapy Y N SpeechTherapy Y N RespiratoryTherapy Y N
DrugAbuse ETOH Abusive:
Physical/Verbal
Physical
Restraints/Sitter
ElopementRisk
MedicalHistory
Current Diagnosisorreasonforhospitalization:
Medical/Surgical History:
Medications:
Mobility
Elimination
Dressing
Bathing
FunctionalAssessmentforNeeds
Supportive Devices Uses Will Need Comments
Indepent ofany
Walker/Cane/Braces Y N Y N WC/Scooter Y N Y N Trapezeinbed Y N Y N Continent Bowel/Bladder Y N
Incontinent Bowel/Bladder Y N
FoleyCatheter Y N Y N
Ostomy Y N Y N Type:
Dressing Independent TotalCare Assistof 1or2
Bathing Independent TotalCare Assistof 1or2
BedMobility Independent TotalCare Assistof 1or2
Toileting Independent TotalCare Assistof 1or2
Labelwound,stageanddimensions