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FACE SHEET – DISCHARGE TO HOME HEALTH

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FACE SHEET – DISCHARGE TO HOME HEALTH Powered By Docstoc
					                                                   Discharge Criteria
       Acceptable Discharge
          (Check all applicable)

       Independent in ADLs________
       Competent/dependable
         caregivers in the home______                 Discharge to retirement home/Assisted living
       Lives alone with generous                                            Appropriate
         support__________________                    Discharge to home health – Complete face sheet
       Stable chronic disease________
       Mentally/cognitively alert_____
       Compliant with instructions___
                                                                Review with patient BEFORE discharge
                                                                           (Check all applicable)
                                                        DNR _____________________________________
                                                        Advance directive ___________________________
                                                        Mental health resources_______________________
              Use Caution                               MSW involvement ___________________________
           Before Discharge                             PT, OT, ST _________________________________
           (Check all applicable)                       Nursing ____________________________________
       Psychological issues ________                    Pharmaceutical review of meds _________________
       No competent/dependable                          Durable medical equipment education____________
         Caregiver________________                      Oxygen company notified before discharge________
       Low literacy_______________                      Medicaid/office of public assistance______________
       Lives alone _______________
                                                        Medicaid Personal Assistance Program___________
       9 or more medications _______
       Oxygen therapy ____________                      Medicaid Self Direct PAS Program ______________
       ADL assistance ____________                      HCBS Waiver Program case management_________
       Transfer __________________                      Social Security ______________________________
       Ambulation _______________                       Noncompliance contract/consequence____________
       PT _____ OT ____ ST ____                         Literacy program education ____________________
       Pressure ulcers ____________                     Cultural barriers _____________________________
       TPN ____________________                         Personal health record_________________________
       IV _____________________

                                                    Swing bed, personal care home and nursing home
                                                                            Appropriate
                                                    Discharge to Home Health - Complete face sheet
                 High Risk
               (Check applicable)
         6 or more indicate high risk for                       HIGH RISK FOR HOSPITALIZATION!
                 emergent care                                  Patient Education/disease specific ______________
Help with managing meds______________                           Hospice Education __________________________
Discharged from a hospital or SNF _______                       Medication management _____________________
Hospitalizations/ER past 12 months ____________                 Caregiver education _________________________
Neoplasm as primary diagnosis________________
No competent/dependable caregiver in home _____
Lives alone _______________________________                                 Appropriate to discharge to nursing
History of noncompliance ___ falls __                                       home & assisted living
ADL needs____ COPD _____ CHF _____                                          Discharge to home health –
Diabetes _____ Chronic skin ulcers ______                                   Complete face sheet
Open wound(s) _____ Confusion _____
Urinary catheter _____ Dyspnea ______
Poor prognosis _____ Short life expectancy _____         Patient Name _________________________________
HIV/AIDS _____ >2 Secondary diagnoses _____              DOB _____________________________________
New diagnosis________ Financial concerns or
         low socioeconomic status ___                    Expected Date of Discharge__________________________

           TOTAL CHECKED                             This material was prepared by Mountain-Pacific Quality Health, the Medicare Quality
                                                     Improvement Organization for Montana, Wyoming, Hawaii and Alaska, under contract with the
                                                     Centers for
                                                     Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human
                                                     Services. Contents do not necessarily reflect CMS policy. Page 1 8thSOW-MPQHF-HHQI-07-06.
             FACE SHEET – DISCHARGE TO HOME HEALTH
   Patient Name_________________________________________ Ht:____Wt:___ Lives Alone (Yes) (No)
   Address:_____________________________________________City__________St_____ Zip_________
   Diagnosis_____________________,_________________________,______________________________
   Physician___________________________________Contact Name_______________________________

   Competent/Dependable Caregiver_________________________________________________________

                               REQUIRED DOCUMENTATION (Please check)

                                                 ***If discharging patient over the            Date of Discharge:_____/_____/_____
   Medicare A_____ Medicare B _____
                                                 weekend, send supplies and                    Date of Assessment____/_____/_____
   Medicare D _____ Medicaid _____
                                                 medication home with patient until            Date of Admission ____/_____/_____
   Private Insurance _____
                                                                                               √ High Risk Referral ____
                                                 home health agency does SOC.

   History & Physical                 ___        Discharge Instruction                         Patient Education:
                                                   Sheet                             ___        Cardio Pulmonary            ___
   Comments:                                                                                    Diabetes                    ___
                                                 Comments:                                      Oxygen                      ___
                                                                                                Medication                   ___
                                                                                                Disease Management           ___
                                                                                                Other                        ___
                                                                                                ________________________________
                                                                                                ________________________________

   Consultation Reports                ___       Discharge Order                    ___        Injectable/Medication Mgmt.
                                                                                                TPN Insert Date:
   Comments:                                     Comments:                                      ______/_____/_____
                                                                                                Antibiotics & Medication
                                                                                                Physician Orders                    ___

   Pertinent Lab X-Ray &                         Advanced Directives,                          Line Care
   Procedure Reports                   ___       Code Status                        ___         PICC Care/                      ___
                                                                                                  Specify Size, Type &
   Comments:                                     Comments:                                        Insert Date:______________________
                                                                                                  _______________________________
                                                                                                 ________________________________

                                                                                                Other Vascular Access
                                                                                                Device:                        ___
                                                                                                Insert Date:_______________________

   Allergy List                      ___         Nutrition                ___                  Wound Care Orders &
   Comments:                                      Enternal Feed/PEG/PEJ                         Instruction                   ___
                                                  Insertion Date:____/___/___                   Wound Vac                     ___
                                                  Other___________________                       Other:__________________________

   PT, OT, ST Evaluations                        Oxygen Therapy                   ___          Catheters                      ___
    & Restrictions                   ___          Physician Orders                ___           Foley Size ______________________
   Comments:                                      Oxygen Provider:                              Insert Date ____/____/___

   DME                        ___                Laboratory                                    Additional Comments:
   Provider Name:                                 Home Health to Draw             ___
   ______________________________                 Discharge Lab                   ___
                                                  Orders__________                ___


   Additional Comments:                          Additional Comments:



This material was prepared by Mountain-Pacific Quality Health, the Medicare Quality Improvement Organization for Montana, Wyoming, Hawaii and
Alaska, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human
Services. Contents do not necessarily reflect CMS policy. Page 2 8thSOW-MPQHF-HHQI-07-06.

				
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