Acute Care Readmission Evaluation Tool
The goal of this tool is to review acute care admissions in order to identify opportunities to improve the coordination of
care across the continuum. Sections 1 through 6 are to be completed by the transferring facility. Sections 7 through
10 are for the acute care facility.
Section 1: BACKGROUND INFORMATION
_______________________________________ ______________________________ _____________________ ________________________
Resident’s Last Name
First Name
Age
a. Date of most recent admission to nursing home: ________/________/________
b. Resident hospitalized in the past 12 months?
Facility Name
No
Unit/Room #
Yes If yes, list dates and reasons below:
Date of Hospitalization
Reason
Section 2: DESCRIBE THE ACUTE CHANGE IN CONDITION THAT LED TO TRANSFER
Date the change in condition first noticed: ________/________/________
a. Check all that apply:
CHANGE IN:
NEW CONDITION:
NEW SYMPTOM(S)/SIGNS OF:
OTHER CHANGE:
Appetite/intake
Bleeding
Altered mental status
Abnormal lab value(s)
Behavior
Breathing difficulty or SOB
Congestive heart failure
Abnormal vital signs
Function
Constipation
Dehydration
Family concern
Skin or a wound
Diarrhea
Fever
Fall
Lower respiratory infection
Pain (new or worsened)
Urinary tract infection
Other (specify)
_____________________
Other (specify)
_____________________
b. Briefly describe the symptom, sign or change in condition that led to the transfer:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________________________________
c. Medication Count ______________
Section 3: EVALUATION AND MANAGEMENT
a. Check all that apply:
TOOLS USED:
MEDICAL EVALUATION:
TESTING:
INTERVENTIONS:
Stop and Watch
Telephone only
Blood tests
New medication
SBAR Progress Note
On-site visit - MD
Urinalysis or culture
IV or SC fluids
Care Path
On-site visit - NP or PA
Xray
Other (specify)
Change in Condition Cards
Other (specify)
b. Briefly describe how the symptoms, signs, or change was evaluated and managed before hospital transfer:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________________________________
c. Was advanced care planning (e.g. DNR, DNH, palliative or hospice care) discussed?
No
Yes, Date:________
Acute Care Readmission Evaluation Tool
Section 4: TRANSFER INFORMATION
Date of transfer: _______/_______/_______ Day (circle): M T W Th F Sa Sn Time of transfer: _____:____ a.m./p.m.
MD authorizing transfer:
Primary MD
Covering MD
Other (________________________)
a. What contributed to the transfer? (Check all that apply):
Abnormal vital signs
MD insisted on transfer
Abnormal lab(s)
Resident preference or insistence
Injury
Family preference or insistence
Worsening condition despite intervention
Other (specify)
b. Were there any relevant factors, social or medical that may have contributed to the transfer in the days before the
transfer?
No
Yes, if yes explain below
c. Briefly describe the main reason(s) for transfer:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Section 5: OPPORTUNITIES FOR IMPROVEMENT
a. After review of how the new symptoms, signs, or other change were evaluated and managed, has your team
identified any opportunities for improvement?
No
Yes If yes, describe briefly
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________________________________
b. In retrospect, does your team think this transfer might have been prevented?
No
Yes If yes, check all that apply and describe briefly
The new sign, symptom, or other change might have been detected earlier
The condition might have been managed safely in the facility without transfer
Advance directives and/or palliative or hospice care could have been discussed
Other (specify)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________________________________
SECTION 6: ADDITIONAL INFORMATION:
_____________________________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________________________
___________________________
Name of person completing Section 1 - 6
________/________/________
Date of completion
Acute Care Readmission Evaluation Tool
The goal of this tool is to review acute care admissions in order to identify opportunities to improve the coordination of
care across the continuum. Sections 1 through 6 are to be completed by the transferring facility. Sections 7 through
10 are for the acute care facility.
Section 7: BACKGROUND INFORMATION INITIAL ADMISSION
_______________________________________ ______________________________ _____________________ ________________________
Patient’s Last Name
First Name
Age
Admitting Location
a. Admitted from: _________________________________
b. Patient Admitted in the past 12 months?
No
Yes If yes, list dates and reasons below and discharge
disposition:
Facility Name
(Discharge Disposition)
Date of Hospitalization
Reason
a. Complaint from Emergency Department:
b. Initial Diagnosis:
c. Briefly describe the main reason(s) for admission
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
d. Advanced directive
No
Yes , if yes, date ______________________
e. Code status _______________________
Section 8: EVALUATION AND MANAGEMENT INITIAL ADMISSION
a. Check all that apply:
SOCIAL SERVICES
DISCHARGE SERVICES
Social services
Home Health
Social service full assessment
Physical Therapy
Palliative Consult
Nursing
Change in Condition Cards
Wound Care
Specialty Appointments
Explain: ______________
Prior to Readmission
Home Health Visit - Date________
Discharge Date:___________
Discharge Location:___________
Discharge Medication Count: _____________
Provider Visit – Date_____________
Acute Care Readmission Evaluation Tool
Section 9: BACKGROUND INFORMATION READMISSION
a. Days between admissions (initial and readmit)
b. Complaint from Emergency Department:
c. Initial Diagnosis:__________________________
d. Was the readmission related to the initial
No
Yes , if yes, describe below
e. Briefly describe the main reason(s) for readmission
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
f. Advanced directive
No
Yes , if yes, date ______________________
g. Code status _______________________
SOCIAL SERVICES
DISCHARGE SERVICES
Social services
Home Health
Social service full assessment
Physical Therapy
Palliative Consult
Nursing
Change in Condition Cards
Wound Care
Specialty Appointments
Explain: ______________
Discharge Date:___________
Discharge Location:___________
Discharge Medication Count: _____________
Section 10: OPPORTUNITIES FOR IMPROVEMENT
a. After review of how the new symptoms, signs, or other change were evaluated and managed, has your team
identified any opportunities for improvement?
No
Yes If yes, describe briefly
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________________________________
b. In retrospect, does your team think this readmission might have been prevented?
No
Yes If yes, check all that apply and describe briefly
The new sign, symptom, or other change might have been detected earlier
The condition might have been managed safely in the facility without transfer
Advance directives and/or palliative or hospice care could have been discussed
Other (specify)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________________________________
Acute Care Readmission Evaluation Tool
SECTION 6: ADDITIONAL INFORMATION:
_____________________________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________________________
___________________________
Name of person completing Section 7-10
________/________/________
Date of completion