Inquiry Date: Potential Discharge Date

Inquiry/Referral Form

Inquiry Date: Potential Discharge Date:

Was Inquiry completed by Phone or Visit? (circle) Attending Physician: Short-­‐term/Long-­‐term (circle one)

Referred by: Contact phone #: _

PAS/OBRA Screen Completed? Y/N by: Hospital Admission Date: (Inpt/Obs/Swing Bed?) Patient Information

Patient: DOB: Sex: M/F Phone:

Home address: City: State: Zip: Marital Status: M S D W Living Will: Y N Code Status: Full Code or DNR Patients Present Location: Previous Hospitalization in last 90 days:

Responsible Party: POA: Y/N Relationship: Phone: Address:

How did you hear about us? Previous resident? Y/N Where?

Expected Payer Source: SSN#: _ Medicare Days Used: Where were Medicare days used at: _ MCR# Medicare screen completed? Yes/No

Does Medicaid Application need to be filed? Y/N MCD#:

Insurance: Policy#: Group#: Name of policy holder: Retirement benefit? Y N Company name if a retirement benefit: Other (VA, Workmen’s comp, etc):

Income/Assets: Social Security Benefits $ Pension $

Criminal History: Y/N for

Circle any of the following diagnosis/conditions applicable during hospital stay: Quadriplegia Multiple Sclerosis Cerebral Palsy Hemiplegia/Hemipareis Septicemia Dehydration Pneumonia Fever

Vaccinations received: type Infection: type _

Inquiry completed by:

Clinical Information

Diet:

HT:

Cognition: A & O to Person Place Time

Tube Feed: WT:

Other/Describe:

Frequency:

Last 14 Days Procedure Occurrence

Date if noted

Will

Cont.

Comments

Extensive

Services

Special

Precautions

Clinically

Complex

Special

Equipment

Rehabilitation

Services

Behavioral Risk Triggers

IV/Saline Lock Y N IV Meds/PICC Y N Trach/Suction Y N Ventilator Y N CPAP/BIPAP/Neb Tx Y N Radiation TX Y N

MRSA VRE C-­‐Diff Y N Source: Blood Wound Urine

Stool Sputum Nares

Oxygen Y N Chemotherapy Y N G-­‐Tube/NG/TPN Y N Transfusion Y N

Ostomy Y N Type:

Dialysis Y N

Bariatric Y N Trapeze Y N Specialty Bed Y N Wound Vac/Supplies Y N

BIPAP/CPAP Y N Rent or Own?

Physical Therapy Y N Occupational Therapy Y N Speech Therapy Y N Respiratory Therapy Y N

Drug Abuse ETOH Abusive:

Physical/Verbal

Physical

Restraints/Sitter

Elopement Risk

Medical History

Current Diagnosis or reason for hospitalization:

Medical/Surgical History:

Medications:

Mobility

Elimination

Dressing

Bathing

Functional Assessment for Needs

Supportive Devices Uses Will Need Comments

Indepent of any

Walker/Cane/Braces Y N Y N WC/Scooter Y N Y N Trapeze in bed Y N Y N Continent Bowel/Bladder Y N

Incontinent Bowel/Bladder Y N

Foley Catheter Y N Y N

Ostomy Y N Y N Type:

Dressing Independent Total Care Assist of 1 or 2

Bathing Independent Total Care Assist of 1 or 2

Bed Mobility Independent Total Care Assist of 1 or 2

Toileting Independent Total Care Assist of 1 or 2

Label wound, stage and dimensions