Post-Acute Transfer Summary and Care Plan
Page 2
Post Acute Task Force
Attachment 4
Proposed Post Acute
Transfer Summary and Care Plan Form
Post-Acute Transfer Summary and Care Plan
Page 2
POST-ACUTE TRANSFER SUMMARY AND CARE PLAN
Part I – Transfer Summary
Patient’s Name ______
Admission date _____/_____/_____ Discharge date _____/_____/_____
1. Hospital contact information:
Hospital ______Unit ______Phone ______
Attending ______PIC # ______Phone ______
Responsible intern or resident:
______PIC # ______Phone ______
2. Primary discharge diagnoses from this hospitalization:
1. ______
2. ______
3. ______
3. Surgical procedures during admission:
1. ______Date _____/_____/_____
2. ______Date _____/_____/_____
4. Other procedures during admission (endoscopies, biopsies, etc.):
1. ______
2. ______
3. ______
5. Vaccination(s) during hospitalization:
____ Influenza _____ Pneumococcal _____ Other (______)
6. Complications (Please describe if present):
_____ Pressure ulcer
_____ Fall with injury
_____ Weight loss (> 10 lbs.)
_____ GI Bleed
_____ Resistant organisms If yes: ___ MRSA ___ VRE ___ Other (______)
_____ Other: ______
7. Medication Allergies, Adverse Reactions
Allergies
Drug Reaction
1. ______
2. ______
3. ______
Adverse Reactions
Drug Reaction
1. ______
2. ______
3. ______
8. Laboratory and other pertinent studies:
See Powerchart or attached copies
9. Consultations during hospitalization:
Service Attending
1. ______
2. ______
3. ______
10. Treatment decisions:
Were DNR, No Hospitalization or other treatment limiting orders discussed during admission?
___ Yes ___ No
If yes, orders decided: ___ DNR ___ No hospitalization ___ No enteral feeding
Other (describe______)
11. Follow-up:
Appointments Scheduled Date and time
1. ______
2. ______
Test/Procedures recommended:
1. ______
2. ______
April 2003 Continued
Post-Acute Transfer Summary and Care Plan
Page 4
POST-ACUTE TRANSFER SUMMARY AND CARE PLAN
Part II – Post Acute Care Plan
Patient’s Name ______Transfer Date _____/_____/_____
1. Admit to (circle):
Subacute (Medicare Skilled)
AG Rhodes Budd Terrace Other ______
Acute Rehab
CRM Wesley Woods
Long Term Acute
Wesley Woods Other ______
Nursing Facility
AG Rhodes Budd Terrace Other ______
2. Advance Directives:
____ DPA ____ Living Will ____ None
Treatment Decisions
____ Full code ____ DNR ____ No hospitalization ____ No enteral feeding
____ Other (specify ______)
3. Vital Signs/Monitoring:
TPR q ______O2 sat q ______
Weigh q ______
Telemetry: ____ No ____ Yes (Indication ______)
4. Activity:
____ Supervised transfer/ambulation
____ Up ad lib
____ Bed rest
5. Precautions:
____ Non-weight bearing
____ Partial weight bearing
____ Weight bearing as tolerated
____ Fall precautions
____ Swallowing/aspiration precautions
____ Seizure precautions
____ Other (specify ______)
6. Dieting/Feedings:
______
______
______
7. Devices:
____ Foley catheter
If present, indicate primary reason:
___ Monitor output ___ Retention (due to ______)
___ Skin precautions ___ Other
____ NG tube
____ Enteral feeding tube
____ PICC line (central)
____ Midline PIC
____ Protective device (specify ______)
____ Other (specify ______)
8. Assessments/Consults:
Rehab Therapies
____ PT ____ OT ____ Speech
Rehab Potential: ____ Good ____ Fair ____ Poor
Rehab Goals: ______
______
Others
____ Respiratory
____ Nutrition
____ Other (specify ______)
9. Wound Care:
______
10. Respiratory Care:
O2 supplementation: ______
Ventilator orders:
FiO2 _____ Rate _____
Mode _____ PEEP _____
Other ______
April 2003 Continued
Post-Acute Transfer Summary and Care Plan
Page 6
11. Medications
Routine:
a. Antibiotics Stop Date
1. ______/____/____
2. ______/____/____
3. ______/____/____
b. DVT prophylaxis/Anticoagulation
1. ______
2. ______
c. GI protection
1. ______
2. ______
Reason: ____ Stress ulcer prophylaxis ____ History of GI bleed
____ Symptomatic GERD ____ Other ______
d. Other routine medications:
1. ______
2. ______
3. ______
4. ______
5. ______
6. ______
7. ______
8. ______
9. ______
10. ______
PRNs:
a. Pain:
1. ______
2. ______
b. Constipation:
1. ______
2. ______
c. Indigestion:
1. ______
d. Other
1. ______
2. ______
3. ______
12. Other recommendations:
Signatures:
Acute Hospital Receiving Facility
Physician ______Physician ______
PIC # ______Date ______/______/______
Nurse ______Nurse ______
PIC # ______Date ______/______/______
April 2003