Patient Release and Followup Form - PDF

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Patient Release and Followup Form document sample

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posted:: 3/7/2011
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MEDICAL/PSYCHIATRIC REFERRAL FORM FOR
SHELTER PLACEMENT
PLEASE NOTE: ONLY LEGIBLE REFERRALS WILL BE REVIEWED.
LEGIBILITY IS THE RESPONSIBILITY OF THE REFERRING FACILITY.

Primary medical inpatient referral Short-term Medical Detox
Primary psychiatric inpatient referral
Medical referral with psychiatric consultation

I. REFERRAL DATA

A. FACILITY INFORMATION:

Facility Name: ______________________________ Contact Person: ______________________________

Telephone: (____) _______-________ x_______ Beeper: (_____) ________-________

Fax: (____) _______-________

B. PATIENT INFORMATION:

Name: _____________________________________ DOB: ____/____/____ SS#:____-___-______

Alias: _____________________________________ HA#: ______________ Sex: M F

Mother’s Maiden Name: _______________________ Marital Status: S M D W Ethnicity: __________

Prior DHS Shelter Resident: Yes No If Yes, where? ___________________ Most recent stay?____________

Citizenship: US Citizen Resident Alien Undocumented Alien Other__________________
US Veteran: Yes No

Able to communicate in English?: Yes No If No, language spoken?________________________________

Benefits: (check if application completed during this hospital admission)

SSI/SSD: Yes No Applied VA: Yes No Applied
PA: Yes No Applied Food Stamps: Yes No Applied
Medicaid: Yes No Applied #: ____________________
Medicare: Yes No #: ___________________
NY/NY Housing Yes No Applied

Amount of Income: $__________________ Other (Income or Insurance): $_________

Next of Kin: ________________________________ (relationship) Phone: (____) _____-__________

Emergency Contact: _________________________ (relationship) Phone: (____) _____-__________

Clinic or Private MD where patient receives care: ___________________________Last visit? _____________________

Telephone or beeper number of PMD: ___________________________________________________________________

Methadone Clinic where patient receives care: _____________________________Phone number: _________________
PATIENT’S NAME: ____________________________, __________________

Medical/Psychiatric Referral Form for Shelter Placement

II. PATIENT’S RELEASE OF INFORMATION AND STATEMENT OF CAPACITY

A. PATIENT’S RELEASE OF INFORMATION:

I, ___________________________________(name of patient), give permission to the medical and social work
staff at __________________________(name of hospital), to release the information below to the Medical
Review Team, the NYC Department of Homeless Services Program Referral Unit and the Social Services
and Medical staff at my assigned shelter. I understand that this information will be used only to help the
hospital and DHS determine if a shelter is an appropriate place for me and, if so, to which shelter I might go.
By giving the information to the Social Services and Medical staff at the shelter to which I will be assigned,
I will be helping them to care for me while I am temporarily living there and avoiding having to repeat the
blood tests and examinations I have had while I have been in the hospital. I agree to this plan for discharge
to a shelter and have rejected, when offered, a more appropriate setting. I understand that I can come into
the shelter system without releasing this information. I know that, if I change my mind about releasing this
information, I can write or ask someone else to write down this decision and give it to a member of my
hospital treating team. I understand that if the information has already been sent, I cannot ask the hospital
to take it back again. I also understand that it is possible that this information will be further disclosed and
will no longer be protected. I have a right to a signed copy of this release form. This release is good for
three months after my discharge from the hospital.

I permit ____________________ (name of hospital) to release the following information:

All information contained in the Medical and Psychiatric Referral Form for Shelter Placement and any
other medical information requested by the Medical Review Team or Program Referral Unit.

Information regarding my HIV status

Information regarding my use of drugs or alcohol.

I understand that only the information checked off can be given to the Medical Review Team/DHS.

Patient’s Signature: _________________________________ Date: ___/___/___
Witness: _________________________________ Date: __/___/____
(Include title, as appropriate.)

B. STATEMENT OF PATIENT’S CAPACITY

As the Physician/Nurse Practitioner/Physician’s Assistant (circle one) primarily responsible for this patient’s inpatient
care, I assert that the information contained in this document reflects accurately the patient’s condition upon admission
and hospital course through discharge, and that, in my clinical judgment, this patient has the capacity to decide to be
discharged to a shelter. I have explained fully to this patient that a shelter has limited, if any, on-site medical care, no
24-hour nursing care and limited medication administration, in some shelters only. We have offered him/her more
appropriate settings, if warranted by his/her medical condition. He/she has, nonetheless, chosen to go/return to a
shelter and, at this time, has full decision-making capacity to do so.

______________________________________ __/__/__ ( ) _____-________
(Name of Physician/NP/PA) (Date) (Pager or phone number)
7/03 2
PATIENT’S NAME: ____________________________, __________________

Medical/Psychiatric Referral Form for Shelter Placement

III. ADMISSION DATA
(Please complete for ALL referrals.)
(All sections, except for “Disposition Planning, Section V (D)(E)(F, if Psych. referral)”, to be completed by MD/NP/PA only.)

DATE OF ADMISSION: ___/___/___

A. REASON FOR ADMISSION:____________________________________________________________________________

B. BRIEF HPI: __________________________________________________________________________________________

______________________________________________________________________________________________________

C. PAST MEDICAL/SURGICAL HISTORY: (please check all that apply) None. Please skip to "D".

AIDS COPD Hepatic disease Rheum. D/O
s/p Amputation CVA HIV+ Seizure hx
Anemia Cystostomy HTN Thyroid D/O
Angina Deafness IDDM Tracheostomy
Asthma Dementia Incontinence
Bleeding diathesis Derm condition Metabolic dysfn Other:
Blindness Dialysis MI ______________
Bone Disease GI condition NIDDM ______________
CAD s/p GSW Pancreatitis ______________
Cancer * GU condition Paralysis ______________
CHF Head trauma Paraplegia ______________
Colostomy Hepatitis Renal disease ______________

1. If Yes to any of the above, please elaborate as needed:

2. *If patient has cancer, please detail which type, when was it dx’ed, and whether the patient underwent any
treatment? Was it metastatic? If so, to where? If newly-diagnosed, what treatment has been recommended?

3. If the patient suffers from cognitive, sensory or motor deficits, please elaborate.

D. PAST PSYCHIATRIC HISTORY: Not applicable (no psychiatric history). Please skip to "E".

(+) symptomatic psychiatric illness; suffering from delirium; or admitted s/p overdose or suicide attempt
ﬁ please obtain and send full psychiatric consultation
(+) stable psychiatric illness (which? ____________________) On meds? Yes No
ﬁ no psychiatric consultation necessary
Inpatients on Psychiatry: Please complete pages 1 – 9 of this form. (Psych Addendum begins on page 8.)

7/03 3
PATIENT’S NAME: ____________________________, __________________

Medical/Psychiatric Referral Form for Shelter Placement

III. ADMISSION DATA
E. SUBSTANCE USE HISTORY: Not applicable (no substance use history). Please skip to "F".

® Current ETOH or Illicit Drug Use? Yes No Unsure

® If yes, please indicate which (check all that apply):

ETOH Cocaine Amphetamines Heroin Methadone THC
PCP Hallucinogens Benzodiazepines Barbiturates
Other: _________________________________________________________________________________________

® Current ETOH-related disorders: Yes No If yes, please check all conditions below that apply:

Falls/Trauma W/drawal sz Delirium Tremens Tremors Blackouts Ascites
Cirrhosis Dementia Varices/GI Bleed Thrombocytopenia Wernicke-Korsakoff’s

® Current ETOH or Drug Treatment? Yes No Unsure
If yes, most recent when and where?

F. ALLERGIES: Yes If Yes, to what?: _________________ No Unknown

IV. HOSPITAL COURSE
A. MED/SURG PROBLEM LIST: Not applicable (patient hospitalized on Psychiatry unit only). Please skip to "B".

ACTIVE PROBLEMS FOLLOW-UP PLANS
1.
2.
3.
4.
5.

INACTIVE PROBLEMS: (Please include major procedures, surgery, diagnostic tests, and unforeseen complications,
extending hospital length of stay (including episodes of delirium, falls, sepsis/infection, bleeding thrombosis/emboli,
acutely compromised immunity, cardiac resuscitation, intubation, or emergency transfusion of blood products).)

1.
2.
3.
4.
5.
6.
7.
8.

7/03 4
PATIENT’S NAME: ____________________________, __________________

Medical/Psychiatric Referral Form for Shelter Placement

IV. HOSPITAL COURSE
B. TB CLEARANCE: Does patient evidence signs or symptoms of active TB? Yes No If No, skip to "C".

® History of TB? Yes No Unknown If Yes, was patient treated? Yes No

If Yes, when, where, and for how long? ______________________________________________________________

® Does the patient have a history of a (+) PPD? Yes No

If Yes, did he/she complete INH/B6 treatment for Latent TB Infection (LTBI)? Yes No
If Yes, when?____________ (month/year)

® PPD+: Was Tuberculosis Skin Testing (PPD) done during this admission? Yes No

If Yes, what were the results? Planted: __/___/___ Read: __/___/___ _______ mm
date) (date)

® If CXR, done __/__/__, consistent with: No disease Old TB Active TB Suspicious for TB
(date)

® Results of AFB Smears x 3 (if done): __/__/__ 1) _______ __/__/__ 2) _______ __/__/__ 3) _______
(date) (date) (date)

® Results of (previous/current) cultures for MTB (if done): __/__/__ 1)_____ __/__/__ 2)______ __/__/__ 3) _____
(date) (date) (date)

ÿ If pt is PPD(+) and either AFB or CXR (-); NYC DOHMH/CDC protocol mandates that the Provider offer/initiate
LTBI treatment with INH/B6. Please confirm that treatment has been initiated. If treatment has not been initiated, the
Provider of record must document the reasons why the patient is not receiving LTBI treatment.

__________________________________________________________________________________________________

C. LAB DATA and DIAGNOSTIC or IMAGING PROCEDURES:

¸ Please send the following lab results (hand-written results or copies of computer record are acceptable):
¸ Please forward most recent labs, reflective of improvement in pt’s condition:

Required:
® Chem 20 ®CBC with differential, platelets

If applicable:
® Therapeutic drug monitoring (TDM) of any measured medication the patient may be taking (INR, if on Warfarin)

® Results of HIV testing, if done; alternatively, T cell count or viral load for any patient with known HIV+ status

® Fasting fingersticks for blood glucose x 3, if suffering from Diabetes Mellitus, and if hospitalized > 3 days

® PT/PTT, if suffering from cirrhosis, other advanced liver disease or coagulopathy of any etiology

® TFTs, for any person presenting with a mood disorder, or as part of a dementia work-up to include:
VDRL, B12/Folate, HIV (if at risk), as well, as imaging procedures (see below).

® Results of Urine or Serum Toxicology, if done on admission. Results of Blood Alcohol Level, if done on admission.

® If CXR performed, please forward formal radiology report. If other diagnostic or imaging procedures were
performed, please attach formal reports or description of findings, if clinically relevant.

7/03 5
PATIENT’S NAME: ____________________________, __________________

Medical/Psychiatric Referral Form for Shelter Placement

V. DISPOSITION PLANNING

A. DIAGNOSES UPON DISCHARGE (please include all diagnoses)(to be completed by MD/NP/PA only):

1. 6.
2. 7.
3. 8.
4. 9.
5. 10

B. MEDICATIONS (to be completed by MD/NP/PA only):

Medication (generic name if possible) Dosage Route Frequency* TDM/Date** Comments (last Dec. given when?)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
* Please use QD or BID dosing as possible; include dosing for Methadone maintenance (MMTP).
** Please document last therapeutic drug monitoring (TDM) level and date.

C. SPECIAL ASSISTANCE NEEDED BY PATIENT UPON DISCHARGE: (to be completed by MD/NP/PA)

® What kind of assistance does patient need with medication administration?
None Needs reminding Needs supervision Needs administration

® Will patient require a special diet upon discharge? Yes No If Yes, please specify diet? _____________
(If Yes, please provide patient with written prescription (Doctor’s order) for diet.)

Has patient been educated regarding choosing among limited food choices in shelter? Yes No

® Does the patient have a wound? Yes No If Yes, please describe:______________________________

_________________________________________________________________________________________________

If Yes, does wound require dressing? Yes No
If Yes, can the patient change the dressing and perform wound care independently? Yes No

® Does patient need specific labs or diagnostic procedures/imaging to be repeated while in shelter? Yes No

If Yes, please document which test and when it should be repeated: ________________________________________
7/03 6
PATIENT’S NAME: ____________________________, __________________

Medical/Psychiatric Referral Form for Shelter Placement

V. DISPOSITION PLANNING
D. SPECIAL FOLLOW-UP NEEDED UPON DISCHARGE: (to be completed by SW/RN/CM)

® Is patient able to manage his/her own money? Yes No Travel independently? Yes No

® Does the patient require any special supplies or nursing care upon discharge? Yes No

Item(s)/help provided: VNS dressing changes syringes glucometer other ________________

® Will patient require any special equipment upon discharge (i.e., wheelchair, cane, walker, etc.)? Yes No
If Yes, please elaborate:

E. REFERRAL TO SHELTER AS LAST RESORT (to be completed by SW/RN/CM))

® Please indicate efforts to place patient outside the shelter system. Please include any general or specific options
explored by SW, with patient’s input, including contact with family, friends or community supports, and the specific
reasons why the patient could not be accommodated in these more appropriate settings. Please list any housing
applications that have been sent, indicating if patient has interviewed at the site.

7/03 7
PATIENT’S NAME: ____________________________, __________________

Psychiatry Addendum: For Inpatient Psychiatry Admissions Only

III. ADMISSION DATA
(This page must be completed by a Psychiatrist or Psych NP only.)

D. PAST PSYCHIATRIC HISTORY: Not applicable (no psychiatric history). Please skip to "IV. A".

® Past OPD treatment? Yes No If Yes, when and where?

® Past Psychiatric Hospitalizations, including State Hospital admissions? Yes No

If yes, #: 0-5 5-10 >10 Most recent, when and where?

® H/O Suicidal Ideation Attempt(s) If Yes, elaborate with dates and nature of suicidal thinking/act:

® H/O Homicidal Ideation Attempt(s) If Yes, elaborate with dates and nature of homicidal thinking/act:

® H/O Violence? Yes No If Yes, elaborate with dates and nature of violent act(s):
Please include history, if known, of fire setting.

® H/O Command Auditory Hallucinations? Yes No
If Yes, elaborate with dates and nature of response, if any, to CAH:

® H/O Medication Trials (and response):

® Non-adherence to medications/treatment: Yes No

® Is patient in AOT? Yes No If Yes, which? Bellevue EGH NCB Woodhull

® Name and page number of ICM/ACT Team: ___________________________________ #:______________________
Psychiatry Addendum: For Inpatient Psychiatry Admissions Only
7/03 8
PATIENT’S NAME: ____________________________, __________________

IV. HOSPITAL COURSE
(This part must be completed by a Psychiatrist or Psych NP only.)

A. PSYCHIATRIC PROBLEM LIST:
ÿ Please include description of pt’s dangerous behavior (towards self or others), if applicable.

ACTIVE PROBLEMS FOLLOW-UP PLANS
1.
2.
3.
4.
5.

INACTIVE PROBLEMS: (Please include neuropsych testing, diagnostic tests, substance-induced disorders (resolved),
adverse medication effects, delirium, NMS, and need for seclusion, restraint, involuntary medication administration
and/or 1:1 observation.)

1.
2.
3,
4.
5.
6.
7.
8.

B. RECENT MENTAL STATUS EXAM: (Done by Psychiatrist/Psych NP only.)

Please attach a copy of an inpatient psychiatrist’s or Psych NP's progress note, dated within the past week, containing a
comprehensive, legible MSE. Please highlight those aspects of the MSE which were found to be abnormal on
admission. For all patients over 65, all patients experiencing Delirium (of any etiology) during this hospital stay and/or
those with known or suspected cognitive impairment, please include a formal (30-pt) Mini-MSE. Please include GAF.

V. DISPOSITION PLANNING
F. SPECIAL PSYCH FOLLOW-UP NEEDED UPON DISCHARGE: (to be completed by SW/RN/CM)(cont'd from p. 7)

® Will patient receive Koskinas follow-up? Yes No
If Yes, please document name and number of Koskinas worker on discharge form. If No, please elaborate why not.

® Has petition for AOT, if submitted, been approved? Yes No

® If Yes, please attach copy of original court order and treatment plan, document AOT team (_______________) and
provide name and number of ICM/ACT team on discharge form.

7/03 9