Multi Disciplinary Hosp Discharge Plan

Agency Multi-Disciplinary Hospital Discharge Plan
Patient Name: Medical Record Number: Birth Date:
Referral Agency: Phone Number: Fax Number:
Admit Date: Discharge Date: Observation Only Status: Yes No
Social Security Number: Medicare Number: Medical Assistance Number:
Insurance Information:
Clinician Signature: ______________________________________ Date: _____________
Instructions: Print completed form for clinician to sign.

Original - Agency  Copies (2): 1) Patient/Family, 2) Medical Records
Patient Name: ______________________________________________ MR#: __________________ DOB: ________________
General Condition Improving Stable Terminal Other:
Rehab Potential Good Fair Poor Terminal
Behavioral None Verbally Abusive Physically Abusive Socially Inappropriate Resists Care:
Symptoms
Mental Status Alert to: Person Place Time Disoriented Not Alert
Impairments None Mental Speech Hearing Vision Dentures Sensation Other:
Communication Makes Self Understood: Always Sometimes Rarely/Never

Understands Others: Always Sometimes Rarely/Never
Mood State No Mood Indicators Indicators Present, Easily Altered Indicators Present, not Easily Altered
Safety Concerns Wandering Impaired Judgment Smoker Awake During Nights Choking Risks
Falls No Falls Reported Fall in Past 30 Days Fall in Last 31-100 Days Date of Last Fall:
Skin Concerns None
Ulcers: Diabetic, location: Venous/Arterial, location:
Pressure, stage , location:
Surgical incision: Other:
Elimination None Bowel Incontinence Bladder Incontinence

Urinary catheter, indwelling Urinary catheter removed, date:
Ostomy, Size of bag: , Equipment:
Pain Symptoms Frequency: No Pain Pain Less Than Daily Daily

Intensity: Mild Moderate Excruciating N/A
Location:
Equipment None Side Rails Trapeze Bed board Restraints Crutches

Walker EZ Stand EZ Lift /Hoyer Cane Wheelchair IV Pump
Shower Chair Commode Hospital Bed Transfer Bench Lift Recliner
Other:
Transportation Car/Family Wheelchair Van Stretcher Van Pick-up Time:
Discharge Diagnosis:
Code Status:
Allergies:
Preadmission Screening Complete: N/A Yes, Date:
Expected Length of Stay: 30 days or less N/A
Behavioral Health Concerns:
Diet: Tube Feeding, formula: rate:
Social Information/Patient Preferences:
Clinician Signature: ______________________________ Date: _____________

2020407 rev0411 Original - Agency  Copies (2): 1) Patient/Family, 2) Medical Records
Advance Directive:
Legal Oversight: None

Power of Attorney: Guardian: Conservator: Healthcare Agent:
Contact Person(s):
Patient Notified of Healthcare and Discharge Plans: Yes No, reason:
Family Notified of Healthcare and Discharge Plans: Yes, who: No, reason:
Therapy Orders: Physical Therapy Occupational Therapy Speech Therapy None
Physical/Occupational Therapy Summary:
Standing Orders: Yes No
Level of Care: Skilled Intermediate Home Health Service Hospice
Clinician Responsible for Care: Clinician Notified: Yes No, because:
Nurse to Complete The Following

Activities of Daily Living Code:
0 = Independent 1 = Supervision 2 = Limited Assist 3 = Extensive Assist 4 = Total Dependence 5 = N/A
Bed Mobility:
Transfer:
Ambulation:
Dressing:
Eating:
Toilet Use:
Personal
Hygiene:
Bathing:
Last Bowel Movement:
Treatment Orders:
Wound Care: N/A Yes, specify:
Medication Orders: See Patient’s Medication List
Medications Given Today and Time: See Patient’s Medication Administration Record
Vaccines, Tetanus: Pneumonia: Flu: Mantoux: Other:
Herpes Zoster Vaccine: If greater than 60 years of age, discuss vaccination with primary care provider.
Height: Weight:
Infections: No Methicillin Resistant Staphylococcus Aureus (MRSA) Vancomycin Resistant Enterococcus (VRE)
Other:

Oxygen: No Yes,
Date Oxygen Last Used: ; Used at home, name of agency:
Intravenous (IV) Used: No Yes, for days; Date last dose given:
Follow-Up Appointments:
Follow-Up Ancillary Testing:
Follow-Up Contact Information: Medical/Surgical Department – 507.529.6800
Nurse to Nurse Report given by:

OMC Nurse to
Facility/Agency Nurse


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Agency Multi-Disciplinary Hospital Discharge Plan

Clinician Signature: ______________________________________ Date: _____________

Instructions: Print completed form for clinician to sign.

Rehab Potential Good Fair Poor Terminal

Communication Makes Self Understood: Always Sometimes Rarely/Never

Elimination None Bowel Incontinence Bladder Incontinence

Pain Symptoms Frequency: No Pain Pain Less Than Daily Daily

Equipment None Side Rails Trapeze Bed board Restraints Crutches

Transportation Car/Family Wheelchair Van Stretcher Van Pick-up Time:

Discharge Diagnosis:

Code Status:

Preadmission Screening Complete: N/A Yes, Date:

Expected Length of Stay: 30 days or less N/A

Behavioral Health Concerns:

Diet: Tube Feeding, formula: rate:

Social Information/Patient Preferences:

Clinician Signature: ______________________________ Date: _____________

Instructions: Print completed form for clinician to sign.

Legal Oversight: None

Contact Person(s):

Therapy Orders: Physical Therapy Occupational Therapy Speech Therapy None

Physical/Occupational Therapy Summary:

Standing Orders: Yes No

Level of Care: Skilled Intermediate Home Health Service Hospice

Nurse to Complete The Following

Bed Mobility:

Toilet Use:

Last Bowel Movement:

Treatment Orders:

Wound Care: N/A Yes, specify:

Medication Orders: See Patient’s Medication List

Height: Weight:

Clinician Signature: ______________________________ Date: _____________

Instructions: Print completed form for clinician to sign.

Oxygen: No Yes,

Follow-Up Appointments:

Follow-Up Ancillary Testing:

Follow-Up Contact Information: Medical/Surgical Department – 507.529.6800

Nurse to Nurse Report given by:

Clinician Signature: ______________________________ Date: _____________

Instructions: Print completed form for clinician to sign.

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