comprehensive . The time of transition of a patient out of ......O2 Saturation Weight Alert...
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Version 4.0 Tool Hospital to Post-Acute Care Data List Contact Information Patient name DOB Language Race/Ethnicity contact name Contact number Representative/ Caregiver/ Proxy contact name ( if different ) Contact number Code Status Full Code DNR (Do Not Resuscitate) DNI (Do Not Intubate ) DNH (Do Not Hospitalize) No artificial feeding Comfort Care Hospice Other Goals of care discussed with patient Yes No Patient capable of making decisions Yes Requires proxy Transferring Information Hospital name Unit Discharging RN Contact number Discharging MD Contact number Post-Acute Care Information Hospital name Contact number Verbal report given Contact name Hospital Physician Care Team Information Primary Care Physician Contact number Specialist Contact number Procedures and Key Findings List procedures Surgeries Imaging Key findings Medications /Allergies Medication list attached Hard copy for controlled substances Allergies Pain medications Dose Last given Nursing Care Physical and Sensory Function Ambulation Independent With assistance With assistive device Not ambulatory Weight bearing Full Partial ( L /R ) None (L/R) Transfer Self 1-Person assist 2-Person assist Sensory Function Sight Hearing Devices Wheelchair Walker Cane Crutches Prosthesis Glasses Contacts Dentures Hearing aid (continued on reverse) © 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 This list is intended to provide guidance on key data elements critical for safe and effective care at the time of transition of a patient out of the hospital to a post-acute care setting. It is not intended to be comprehensive . The INTERACT Hospital to Post-Acute Care Transfer Form illustrates an example of ho w these data can be formatted so that the data are readily accessible for receiving clinicians. Representative/Caregiver/Proxy High Risk Conditions Fall risk Heart failure New diagnosis Exacerbation this admission Date of last echo EF Dry weight Anticoagulation Reason Goal of International Normalization Ratio On PPI Indication(s) On Antibiotics Indication(s) Course of treatment Most recent glucose Mental Status Alert Disoriented, follows commands Disoriented, cannot follow commands Not alert Primary discharge diagnosis Other Medical Diagnoses Mental Health Diagnoses Diagnoses On Scheduled Insulin Key Clinical Information Vital Signs Time taken Pain rating Pain site Temperature BP HR RR O2 Saturation Weight
Transcript of comprehensive . The time of transition of a patient out of ......O2 Saturation Weight Alert...
V er s ion 4 .0 Too l
©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.
Hospital to Post-Acute Care Data List
This list is intended to provide guidance on key data elements critical for safe and effective care at the time of transition of a patient out of the hospital to a post-acute care setting. It is not intended to be
Contact Information Patient name
DOB
Language
Race/Ethnicity
Family/Caregiver/Proxy contact name Contact number
Representative/Caregiver/Proxy contact name ( if different) Contact number
Code StatusFull Code
DNR (Do Not Resuscitate)
DNI (Do Not Intubate)
DNH (Do Not Hospitalize)
No artificial feeding
Comfort Care
Hospice
Other
Goals of care discussed with patient Yes No
Patient capable of making decisions Yes Requires proxy
Transferring InformationHospital name
Unit
Discharging RN Contact number
Discharging MD Contact number
Post-Acute Care InformationHospital name
Contact number
Verbal report given Contact name
Hospital Physician Care Team InformationPrimary Care Physician
Contact number
Specialist Contact number
Key Clinical InformationVital Signs
Time taken
Pain rating
Pain site
Temperature
BP
HR
RR
O2 Saturation
Weight
Mental Status
Alert
Disoriented, follows commands
Disoriented, cannot follow commands
Not alert
High Risk ConditionsFall risk
Heart failure New diagnosis Exacerbation this admission Date of last echo EF Dry weight
Anticoagulation Reason Goal of International Normalization Ratio
On PPI Indication(s)
On Antibiotics Indication(s) Course of treatment
Diabetic Most recent glucose
Procedures and Key Findings List procedures Surgeries Imaging
Key findings
Medications/AllergiesMedication list attached
Hard copy for controlled substances
Allergies
Pain medications Dose Last given
Nursing CarePhysical and Sensory Function
Ambulation Independent With assistance With assistive device Not ambulatory
Weight bearing Full Partial ( L /R ) None ( L /R )
Transfer Self 1-Person assist 2-Person assist
Sensory Function Sight Hearing
Devices Wheelchair Walker Cane Crutches Prosthesis Glasses Contacts Dentures Hearing aid
(continued on reverse)
© 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
This list is intended to provide guidance on key data elements critical for safe and effective care at the time of transition of a patient out of the hospital to a post-acute care setting. It is not intended to be comprehensive . The INTERACT Hospital to Post-Acute Care Transfer Form illustrates an example of ho w these data can be formatted so that the data are readily accessible for receiving clinicians.
Representative/Caregiver/Proxy
V er s ion 4 .0 Too l
©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.
Hospital to Post-AcuteCare Data List
This list is intended to provide guidance on key data elements critical for safe and effective care at thetime of transition of a patient out of the hospital to a post-acute care setting. It is not intended to becomprehensive. The INTERACT Hospital Post-Acute Care Transfer Form illustrates an example of howthese data can be formatted so that the data are readily accessible for receiving clinicians.
Contact InformationPatient name
DOB
Language
Race/Ethnicity
Family/Caregiver/Proxycontact nameContact number
Family/Caregiver/Proxycontact name ( if different)Contact number
Code StatusFull Code
DNR (Do Not Resuscitate)
DNI (Do Not Intubate)
DNH (Do Not Hospitalize)
No artificial feeding
Comfort Care
Hospice
Other
Goals of care discussed with patientYesNo
Patient capable of making decisionsYesRequires proxy
Transferring InformationHospital name
Unit
Discharging RNContact number
Discharging MDContact number
Post-Acute Care InformationHospital name
Contact number
Verbal report given Contact name
Hospital Physician CareTeam InformationPrimary Care PhysicianContact number
SpecialistContact number
Key Clinical InformationVital Signs
Time taken
Pain rating
Pain site
Temperature
BP
HR
RR
O2 Saturation
Weight
Mental Status
Alert
Disoriented, follows commands
Disoriented, cannot followcommands
Not alert
High Risk ConditionsFall risk
Heart failure New diagnosis Exacerbation this admission Date of last echo EF Dry weight
Anticoagulation Reason Goal of International Normalization Ratio
On PPI Indication(s)
On Antibiotics Indication(s) Course of treatment
Diabetic Most recent glucose
Procedures and Key FindingsList proceduresSurgeriesImaging
Key findings
Medications/AllergiesMedication list attached
Hard copy for controlledsubstances
Allergies
Pain medicationsDoseLast given
Nursing CarePhysical and Sensory Function
AmbulationIndependentWith assistance With assistive device Not ambulatory
Weight bearing Full Partial ( L /R ) None ( L /R )
TransferSelf1-Person assist2-Person assist
Sensory FunctionSightHearing
Devices Wheelchair Walker Cane Crutches Prosthesis Glasses Contacts Dentures Hearing aid
(continued on reverse)
V er s ion 4 .0 Too l
©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.
Hospital to Post-AcuteCare Data List
This list is intended to provide guidance on key data elements critical for safe and effective care at thetime of transition of a patient out of the hospital to a post-acute care setting. It is not intended to becomprehensive. The INTERACT Hospital Post-Acute Care Transfer Form illustrates an example of howthese data can be formatted so that the data are readily accessible for receiving clinicians.
Contact InformationPatient name
DOB
Language
Race/Ethnicity
Family/Caregiver/Proxycontact nameContact number
Family/Caregiver/Proxycontact name ( if different)Contact number
Code StatusFull Code
DNR (Do Not Resuscitate)
DNI (Do Not Intubate)
DNH (Do Not Hospitalize)
No artificial feeding
Comfort Care
Hospice
Other
Goals of care discussed with patientYesNo
Patient capable of making decisionsYesRequires proxy
Transferring InformationHospital name
Unit
Discharging RNContact number
Discharging MDContact number
Post-Acute Care InformationHospital name
Contact number
Verbal report given Contact name
Hospital Physician CareTeam InformationPrimary Care PhysicianContact number
SpecialistContact number
Key Clinical InformationVital Signs
Time taken
Pain rating
Pain site
Temperature
BP
HR
RR
O2 Saturation
Weight
Mental Status
Alert
Disoriented, follows commands
Disoriented, cannot follow commands
Not alert
High Risk ConditionsFall risk
Heart failureNew diagnosisExacerbation this admissionDate of last echoEFDry weight
AnticoagulationReasonGoal of International
Normalization Ratio
On PPIIndication(s)
On AntibioticsIndication(s)Course of treatment
DiabeticMost recent glucose
Procedures and Key FindingsList proceduresSurgeriesImaging
Key findings
Medications/AllergiesMedication list attached
Hard copy for controlledsubstances
Allergies
Pain medicationsDoseLast given
Nursing CarePhysical and Sensory Function
AmbulationIndependentWith assistance With assistive device Not ambulatory
Weight bearing Full Partial ( L /R ) None ( L /R )
TransferSelf1-Person assist2-Person assist
Sensory FunctionSightHearing
Devices Wheelchair Walker Cane Crutches Prosthesis Glasses Contacts Dentures Hearing aid
(continued on reverse)
Primary discharge diagnosisOther Medical DiagnosesMental Health Diagnoses
Diagnoses
On Scheduled Insulin
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©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.
Hospital to Post-AcuteCare Data List
This list is intended to provide guidance on key data elements critical for safe and effective care at thetime of transition of a patient out of the hospital to a post-acute care setting. It is not intended to becomprehensive. The INTERACT Hospital Post-Acute Care Transfer Form illustrates an example of howthese data can be formatted so that the data are readily accessible for receiving clinicians.
Contact InformationPatient name
DOB
Language
Race/Ethnicity
Family/Caregiver/Proxycontact nameContact number
Family/Caregiver/Proxycontact name ( if different)Contact number
Code StatusFull Code
DNR (Do Not Resuscitate)
DNI (Do Not Intubate)
DNH (Do Not Hospitalize)
No artificial feeding
Comfort Care
Hospice
Other
Goals of care discussed with patientYesNo
Patient capable of making decisionsYesRequires proxy
Transferring InformationHospital name
Unit
Discharging RNContact number
Discharging MDContact number
Post-Acute Care InformationHospital name
Contact number
Verbal report given Contact name
Hospital Physician CareTeam InformationPrimary Care PhysicianContact number
SpecialistContact number
Key Clinical InformationVital Signs
Time taken
Pain rating
Pain site
Temperature
BP
HR
RR
O2 Saturation
Weight
Mental Status
Alert
Disoriented, follows commands
Disoriented, cannot followcommands
Not alert
High Risk ConditionsFall risk
Heart failureNew diagnosisExacerbation this admissionDate of last echoEFDry weight
AnticoagulationReasonGoal of International
Normalization Ratio
On PPIIndication(s)
On AntibioticsIndication(s)Course of treatment
DiabeticMost recent glucose
Procedures and Key FindingsList proceduresSurgeriesImaging
Key findings
Medications/AllergiesMedication list attached
Hard copy for controlledsubstances
Allergies
Pain medicationsDoseLast given
Nursing CarePhysical and Sensory Function
AmbulationIndependentWith assistance With assistive device Not ambulatory
Weight bearing Full Partial ( L /R ) None ( L /R )
TransferSelf1-Person assist2-Person assist
Sensory FunctionSightHearing
Devices Wheelchair Walker Cane Crutches Prosthesis Glasses Contacts Dentures Hearing aid
(continued on reverse)
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©2014 Florida Atlantic University, all rights reserved.
Hospital to Post-Acute Care Data List (cont’d)
Nursing Care (continued) Continence Continent Bladder incontinent Catheter (use/indication) Date inserted Bowel incontinent Ostomy
Nutrition and Hydration
Diet
Consistency
Free water restriction
Eating Instructions Self With assistance Difficulty swallowing Attach speech therapy recommendations if available
Tube feeding G-tube J-tube Date inserted
Free Water Bolus
Tube feed product Rate Duration
Treatment and Therapeutic Devices
PICC
Portocath Date inserted
Cardiac Pacemaker ICD Other
Respiratory CPAP BiPAP O2
Therapies
Physical Therapy
Occupational Therapy
Speech
Respiratory
Dialysis
Skin Care
No skin breakdown
Pressures ulcer Stage Location
Other wounds
Risks and Precautions
Fall
Delirium
Agitation
Aggression
Unescorted exiting
Aspiration
Other
Infection Control Issues
Infection/Colonization MRSA VRE C. difficile ESBL Norovirus Flu/respiratory
Isolation Precautions None Contact Contact-Plus Droplet Airborne
Immunizations Influenza Date Pneumococcal Date
Critical Transitional Care Information Summary of high-priority care within the next 24 hrs
Pending lab and test results
Recommended follow-up Tests Procedures Appointments
Attached Documents (examples) Admission H&P
Specialist consultations
Medication reconciliation
Operative reports
Diagnostic studies
Labs
Diabetic glucose values
PICC placement confirmation
Rehab therapy notes
Respiratory therapy notes
Nutrition notes
Pain ratings
Code status
Advance directives
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 of Florida Atlantic University. Updated June 2018
V er s ion 4 .0 Too l
©2014 Florida Atlantic University, all rights reserved.
Hospital to Post-Acute Care Data List (cont’d)
Nursing Care (continued) Continence Continent Bladder incontinent Catheter (use/indication) Date inserted Bowel incontinent Ostomy
Nutrition and Hydration
Diet
Consistency
Free water restriction
Eating Instructions Self With assistance Difficulty swallowing Attach speech therapy recommendations if available
Tube feeding G-tube J-tube Date inserted
Free Water Bolus
Tube feed product Rate Duration
Treatment and Therapeutic Devices
PICC
Portocath Date inserted
Cardiac Pacemaker ICD Other
Respiratory CPAP BiPAP O2
Therapies
Physical Therapy
Occupational Therapy
Speech
Respiratory
Dialysis
Skin Care
No skin breakdown
Pressures ulcer Stage Location
Other wounds
Risks and Precautions
Fall
Delirium
Agitation
Aggression
Unescorted exiting
Aspiration
Other
Infection Control Issues
Infection/Colonization MRSA VRE C. difficile ESBL Norovirus Flu/respiratory
Isolation Precautions None Contact Contact-Plus Droplet Airborne
Immunizations Influenza Date Pneumococcal Date
Critical Transitional Care Information Summary of high-priority care within the next 24 hrs
Pending lab and test results
Recommended follow-up Tests Procedures Appointments
Attached Documents (examples) Admission H&P
Specialist consultations
Medication reconciliation
Operative reports
Diagnostic studies
Labs
Diabetic glucose values
PICC placement confirmation
Rehab therapy notes
Respiratory therapy notes
Nutrition notes
Pain ratings
Code status
Advance directives
Discharge summary
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©2014 Florida Atlantic University, all rights reserved.
Hospital to Post-Acute Care Data List (cont’d)
Nursing Care (continued) Continence Continent Bladder incontinent Catheter (use/indication) Date inserted Bowel incontinent Ostomy
Nutrition and Hydration
Diet
Consistency
Free water restriction
Eating Instructions Self With assistance Difficulty swallowing Attach speech therapy recommendations if available
Tube feeding G-tube J-tube Date inserted
Free Water Bolus
Tube feed product Rate Duration
Treatment and Therapeutic Devices
PICC
Portocath Date inserted
Cardiac Pacemaker ICD Other
Respiratory CPAP BiPAP O2
Therapies
Physical Therapy
Occupational Therapy
Speech
Respiratory
Dialysis
Skin Care
No skin breakdown
Pressures ulcer Stage Location
Other wounds
Risks and Precautions
Fall
Delirium
Agitation
Aggression
Unescorted exiting
Aspiration
Other
Infection Control Issues
Infection/Colonization MRSA VRE C. difficile ESBL Norovirus Flu/respiratory
Isolation Precautions None Contact Contact-Plus Droplet Airborne
Immunizations Influenza Date Pneumococcal Date
Critical Transitional Care Information Summary of high-priority care within the next 24 hrs
Pending lab and test results
Recommended follow-up Tests Procedures Appointments
Attached Documents (examples) Admission H&P
Specialist consultations
Medication reconciliation
Operative reports
Diagnostic studies
Labs
Diabetic glucose values
PICC placement confirmation
Rehab therapy notes
Respiratory therapy notes
Nutrition notes
Pain ratings
Code status
Advance directives
Discharge summary
Continent
Retention
Incontinent
Skin Protection
Urinary Catheter in place
Monitor Output
Date insertedReason for Catheter
Bladder Function
ContinentIncontinentOstomyDate of last bowel movement
Bowel Function
TPN
Pressures ulcer/injury
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©2014 Florida Atlantic University, all rights reserved.
Hospital to Post-Acute Care Data List (cont’d)
Nursing Care (continued) Continence Continent Bladder incontinent Catheter (use/indication) Date inserted Bowel incontinent Ostomy
Nutrition and Hydration
Diet
Consistency
Free water restriction
Eating Instructions Self With assistance Difficulty swallowing Attach speech therapy recommendations if available
Tube feeding G-tube J-tube Date inserted
Free Water Bolus
Tube feed product Rate Duration
Treatment and Therapeutic Devices
PICC
Portocath Date inserted
Cardiac Pacemaker ICD Other
Respiratory CPAP BiPAP O2
Therapies
Physical Therapy
Occupational Therapy
Speech
Respiratory
Dialysis
Skin Care
No skin breakdown
Pressures ulcer Stage Location
Other wounds
Risks and Precautions
Fall
Delirium
Agitation
Aggression
Unescorted exiting
Aspiration
Other
Infection Control Issues
Infection/Colonization MRSA VRE C. difficile ESBL Norovirus Flu/respiratory
Isolation Precautions None Contact Contact-Plus Droplet Airborne
Immunizations Influenza Date Pneumococcal Date
Critical Transitional Care Information Summary of high-priority care within the next 24 hrs
Pending lab and test results
Recommended follow-up Tests Procedures Appointments
Attached Documents (examples) Admission H&P
Specialist consultations
Medication reconciliation
Operative reports
Diagnostic studies
Labs
Diabetic glucose values
PICC placement confirmation
Rehab therapy notes
Respiratory therapy notes
Nutrition notes
Pain ratings
Code status
Advance directives
Discharge summary
