RED Discharge Preparation Workbook
This workbook available for download in two formats:
PDF - 70.32 KB
Microsoft Word - 40.19 KB
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Patient Name _________________________ MRN ________________ DOB ______________ Room # ______________ Date of admission ______________ |
| Language preference | Interpreter/Translation Needed (Y/N) |
|
|---|---|---|
| Spoken communication | ||
| Written materials | ||
| Phone communication |
Fill out Contact Sheet for patient, proxy, and caregiver contact information.
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MEDICAL TEAM ______ Attending: ________________________________ _________________________________________ _________________________________________ Case Manager: ___________________________ Language Services: _______________________ Family worker: ____________________________ |
Pages to Team:
| Pager: _____ Time: _____ C/B?: Y N | Pager: _____ Time: _____ C/B?: Y N | Pager: _____ Time: _____ C/B?: Y N |
| Pager: _____ Time: _____ C/B?: Y N | Pager: _____ Time: _____ C/B?: Y N | Pager: _____ Time: _____ C/B?: Y N |
| Pager: _____ Time: _____ C/B?: Y N | Pager: _____ Time: _____ C/B?: Y N | Pager: _____ Time: _____ C/B?: Y N |
| Pager: _____ Time: _____ C/B?: Y N | Pager: _____ Time: _____ C/B?: Y N | Pager: _____ Time: _____ C/B?: Y N |
DE Time: (Record time spent on patient's case)
| Date: ______ DE: ____ Total: ______ | Date: ______ DE: ____ Total: ______ | Date: ______ DE: ____ Total: ______ |
| Date: ______ DE: ____ Total: ______ | Date: ______ DE: ____ Total: ______ | Date: ______ DE: ____ Total: ______ |
| Date: ______ DE: ____ Total: ______ | Date: ______ DE: ____ Total: ______ | Date: ______ DE: ____ Total: ______ |
Floor Nurse: (Name of patient's nurse)
| Date: _______ Nurse: __________ | Date: _______ Nurse: __________ | Date: _______ Nurse: __________ |
| Date: _______ Nurse: __________ | Date: _______ Nurse: __________ | Date: _______ Nurse: __________ |
| Date: _______ Nurse: __________ | Date: _______ Nurse: __________ | Date: _______ Nurse: __________ |
Contacts with family/caregiver
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Date: _______ Name: __________ Date: _______ Name: _________ Date: _______ Name: __________ |
| Date | Outstanding Patient Teaching/Information | Date Addressed |
|---|---|---|
1. Diagnoses
Admitting Dx: ____________________________________________________________________________
Comorbidities: ___________________________________________________________________________
Discharge Dxs ___________________________________________________________________________
2. Followup Appointments
PCP Appointment
____ Patient has PCP? If NO, Preferences (gender, location)? ___________________________________
Patient requests for PCP appt (weekdays, time of day): ________________________________________
| PCP Name | Day / Date / Time |
| Clinician to see at appt (if not PCP) |
Location |
| Address/Floor: Phone #: Fax #: |
Does patient have transportation to PCP appt?
____ Yes ___ No ____ Transportation options discussed:
Team appt. requests: _____________________________________________________________________
Additional Appointments, Tests, or Lab Work to be done POSTDISCHARGE
****Attach Additional Appointment Sheet if Needed****
| Day / Date / Time | Phone and Fax # | Reason / Test / Lab |
| Ph: Fax: |
||
| Provider | Location (Address, floor) | |
| How patient will get to appointment | ||
| Day / Date / Time | Phone and Fax # | Reason / Test / Lab |
| Ph: Fax: |
||
| Provider | Location (Address, floor) | |
| How patient will get to appointment | ||
| Day / Date / Time | Phone and Fax # | Reason / Test / Lab |
| Ph: Fax: |
||
| Provider | Location (Address, floor) | |
| How patient will get to appointment | ||
| Day / Date / Time | Phone and Fax # | Reason / Test / Lab |
| Ph: Fax: |
||
| Provider | Location (Address, floor) | |
| How patient will get to appointment | ||
| Day / Date / Time | Phone and Fax # | Reason / Test / Lab |
| Ph: Fax: |
||
| Provider | Location (Address, floor) | |
| How patient will get to appointment | ||
| Day / Date / Time | Phone and Fax # | Reason / Test / Lab |
| Ph: Fax: |
||
| Provider | Location (Address, floor) | |
| How patient will get to appointment | ||
3. Medicine
Allergies ____ No known allergies ____
| Allergy | Patient Confirm (Y/N) |
If No, Explain | Allergy | Patient Confirm (Y/N) |
If No, Explain |
|---|---|---|---|---|---|
4. Pharmacy
Uses hospital pharmacy? No ____ Yes ____
| Labs/Tests Pending | Community Pharmacy Name | Phone #, Street Address, City |
|---|---|---|
Pt. plan to pick up meds upon d/c: ______________________________________________________
Pt. requests pill box? No ____ Yes ____ (Pill box given ____)
5. Diet
| Discharge diet | Pt. needs diet info. _____________________________ |
6. Substance use
| Substance | SCM | Patient Report | Current Tx. or Interested in Cessation Info? |
|---|---|---|---|
| Alcohol | |||
| Tobacco |
7. Durable medical equipment needed at home?
No ____ Yes ____
If pt. checks blood sugar with glucometer, how many times daily? _______
New durable medical equipment ordered: Yes ____ No ____
Type ____________________________________________________________________________________
Company name: __________________ Contact: _______________________________________________
Address: __________________________ Phone: _______________________________________________
Delivery date: ____________________________________________________________________________
Type ____________________________________________________________________________________
Company name: __________________ Contact: _______________________________________________
Address: __________________________ Phone: _______________________________________________
Delivery date: ____________________________________________________________________________
8. Current or New Outpatient Services (ex. VNA, PT)? _______________________________
Service __________________________________________________________________________________
Company name: __________________ Contact: _______________________________________________
Address: __________________________ Phone: _______________________________________________
Date scheduled: __________________________________________________________________________
Service __________________________________________________________________________________
Company name: __________________ Contact: _______________________________________________
Address: __________________________ Phone: _______________________________________________
Date scheduled: __________________________________________________________________________
Service __________________________________________________________________________________
Company name: __________________ Contact: _______________________________________________
Address: __________________________ Phone: _______________________________________________
Date scheduled: __________________________________________________________________________
9. Outstanding Tests/Labs
| Labs/Tests Pending | Date Conducted | Results Expected | Who Will Follow Up on the Result |
|---|---|---|---|
Final teaching completed? Yes ____ Done by: DE ____ Other ________________ No ____
Reviewed what to do about problems? Yes ____ No ____
Patient understanding confirmed? Yes ____ No ____
Medicines reconciled with patient and medical team prior to final teaching? Yes ____ No ____
National guidelines checked prior to final teaching? Yes ____ Date: _________ No ____
AHCP given and reviewed by DE with patient?
Yes ____ Time spent: ____minutes DE____
No ____ Date mailed: _________
If mailed, was patient called by DE to review AHCP? Yes ____ Date: __________ DE ____ No ____
Communication/Notes
