UNIVERSITY OF NEW MEXICO HOSPITAL DISCHARGE TO ANOTHER HEALTHCARE FACILITY

Date:

Patient Name: Medical Record #:

Admission Date:Discharge Date:

Discharging Attending of record: Phone: (505) 272-2000 - PALS

Nurse Case Manager: Phone: (505) 272-2328 – Main Office

Discharging Unit:Phone: Service:

Admit To (Name of Facility):

Facility Type: □Long Term Acute Care □Skilled Nursing □Rehab □Long Term Care □Inpatient Hospice

□Acute Care Transfer: ______□ Other: ______

Admission Diagnosis to Facility:

Discharging Diagnosis from UNMH:

Secondary Diagnosis:

Allergies:

Patient Has DECISIONAL MAKING CAPACITY : YES NO

If patient DOES NOT have decisional capacity:

Power of Attorney OR Appointed Guardian

Name:Phone:

Next of Kin:

Name:Phone:

NURSING

1. Vital Signs: Routine Other:

2. Weigh Patient: On admission DailyWeekly Other:

3. Foley Cather per protocol with daily intake/output

Date cather inserted:For Diagnosis:

Recommendations/Remove:

4. Diet:

Nutrition recommendations:

5. Fluid Restrict:

6. Oxygen:

7. IV Fluids (type and rate):

8. Nebulized treatments:

9. For temperature GREATER than 100.6F notify MD and obtain urinalysis and culture, blood cultures X2 different sites (one from PICC if applicable) and portable chest Xray diagnosis “fever”

10. PPD (to be done on ALL admissions unless status is known or refused)

Most recent result and date (if known):

11. Notes on patient limitations/disabilities/barriers to care:

12. Other:

THERAPY/CONSULTS

1. Physical Therapy Consult – Functional Mobility

Our recommendations:

ACTIVITY: WEIGHT BEARING STATUS:

2. Occupational Therapy Consult – ADLs and adaptive equipment

Our recommendations:

3. Speech Therapy Consult – Language and Swallow

Our recommendations:

4. Respiratory Therapy – Pulmonary Rehab

5. Wound Care Nurse to see patient for:

Our recommendations:

MEDICATIONS

IF PRESCRIBING COUMADIN or OTHER ANTICOAGULATION (LMWH/Fondaparinux/Other):

*Note DIAGNOSIS, GOAL INR, recent INR/date, frequency of drawsrecommended LENGTH OF TREATMENT.

* ORDER for Facility: “PLEASE MAINTAIN COUMADIN/ANTICOAGULATION SHEET”

IF PRESCRIBING MEDICATIONS that require MONITORING OF LEVELS:

*Note most recent level/date and recommendations on monitoring

FOR INFECTIOUS DISEASE MEDICATIONS include duration of treatment/stop date and diagnosis

*DO NOT FORGET to provide orders for monitoring of labs (renal, liver, CBC, ESR, etc per medication prescribed)

LABS (as above)

IF ORDERING LABS please also make a brief note of what to consider/do if there is an abnormal result.

FOLLOW-UP APPOINTMENTS:

Primary Care Provider (NAME) / (DATE) / (PHONE)
(Specialty) (NAME) / (DATE) / (PHONE)

PENDING RESULTS AT THE TIME OF DISCHARGE:

OTHER RECOMMENDATIONS:

Physician Signature______Date______

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Revised 01/2010