Agency Multi-Disciplinary Hospital Discharge Plan
Patient Name:
Referral Agency:
Admit Date:
Social Security Number:
Insurance Information:
Medical Record Number:
Phone Number:
Discharge Date:
Medicare Number:
General Condition
Improving
Rehab Potential
Good
Fair
Behavioral
Symptoms
None
Verbally Abusive
Mental Status
Impairments
Communication
Alert to:
Stable
Poor
Person
None
Terminal
Physically Abusive
Time
Speech
No Mood Indicators
Safety Concerns
Wandering
Falls
No Falls Reported
Skin Concerns
None
Ulcers:
Disoriented
Hearing
Resists Care:
Not Alert
Vision
Dentures
Indicators Present, Easily Altered
Impaired Judgment
None
Diabetic, location:
Pressure, stage
Sensation
Other:
Urinary catheter, indwelling
Size of bag:
Frequency:
Intensity:
No Pain
Mild
Indicators Present, not Easily Altered
Awake During Nights
Fall in Last 31-100 Days
Choking Risks
Date of Last Fall:
Venous/Arterial, location:
, location:
Other:
Bowel Incontinence
Ostomy,
Smoker
Fall in Past 30 Days
Surgical incision:
Pain Symptoms
Socially Inappropriate
Makes Self Understood:
Always
Sometimes
Rarely/Never
Understands Others:
Always
Sometimes
Rarely/Never
Mood State
Elimination
Other:
Terminal
Place
Mental
Birth Date:
Fax Number:
Observation Only Status:
Yes
Medical Assistance Number:
Bladder Incontinence
Urinary catheter removed, date:
,
Equipment:
Pain Less Than Daily
Moderate
Excruciating
Daily
N/A
Location:
Equipment
None
Side Rails
Walker
EZ Stand
Shower Chair
Commode
Other:
Transportation
Car/Family
Wheelchair Van
Trapeze
Bed board
Restraints
Crutches
EZ Lift /Hoyer
Cane
Wheelchair
IV Pump
Hospital Bed
Transfer Bench
Lift Recliner
Stretcher Van
Pick-up Time:
Discharge Diagnosis:
Code Status:
Allergies:
Clinician Signature: ______________________________________
Date: _____________
Instructions: Print completed form for clinician to sign.
Original - Agency  Copies (2): 1) Patient/Family, 2) Medical Records
No
Patient Name: ______________________________________________
Preadmission Screening Complete:
Expected Length of Stay:
N/A
30 days or less
MR#: __________________ DOB: ________________
Yes, Date:
N/A
Behavioral Health Concerns:
Diet:
Tube Feeding, formula:
rate:
Social Information/Patient Preferences:
Advance Directive:
Legal Oversight:
None
Power of Attorney:
Guardian:
Conservator:
Healthcare Agent:
Contact Person(s):
Patient Notified of Healthcare and Discharge Plans:
Yes
Family Notified of Healthcare and Discharge Plans:
Yes, who:
Therapy Orders:
Physical Therapy
No, reason:
Occupational Therapy
No, reason:
Speech Therapy
None
Physical/Occupational Therapy Summary:
Standing Orders:
Level of Care:
Yes
No
Skilled
Intermediate
Home Health Service
Clinician Responsible for Care:
Clinician Notified:
Hospice
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
Bed Mobility:
Transfer:
Ambulation:
Dressing:
Eating:
Toilet Use:
Personal
Hygiene:
Bathing:
Last Bowel Movement:
Treatment Orders:
Wound Care:
N/A
Medication Orders:
Yes, specify:
See Patient’s Medication List
Clinician Signature: ______________________________
2020407 rev0411
Date: _____________
Instructions: Print completed form for clinician to sign.
Original - Agency  Copies (2): 1) Patient/Family, 2) Medical Records
5 = N/A
Patient Name: ______________________________________________
Medications Given Today and Time:
Vaccines,
Tetanus:
MR#: __________________ DOB: ________________
See Patient’s Medication Administration Record
Pneumonia:
Flu:
Mantoux:
Other:
Herpes Zoster Vaccine: If greater than 60 years of age, discuss vaccination with primary care provider.
Height:
Infections:
Other:
Oxygen:
Weight:
No
No
Methicillin Resistant Staphylococcus Aureus (MRSA)
Vancomycin Resistant Enterococcus (VRE)
Yes,
Date Oxygen Last Used:
Intravenous (IV) Used:
;
No
Used at home, name of agency:
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
Clinician Signature: ______________________________
2020407 rev0411
Date: _____________
Instructions: Print completed form for clinician to sign.
Original - Agency  Copies (2): 1) Patient/Family, 2) Medical Records