Please Credit Christine Nelson, RN, PhD, Oregon Health & Science University

Patient ID Code: ______

OR HOSPITAL CHART REVIEW FORM

1. Today’s Date ______

2. Age in Years ______

3. Gender

 Female Male

4. Race/Ethnicity:

 White African American/Black  Native Hawaiian/Pacific Islander  Asian  American Indian/Alaskan Native  Hispanic  Other  not available

5. Education

 No Schooling 8th Grade/less 9 – 11th grades

 High School Technical/trade school some college

 Bachelor’s degree  Graduate degree  not available

6. Discharge destination

 Bethany St. Joseph’s Bethany Riverside Hillview

 St. Joseph’s Onalaska Care Mulders

 Lakeview Rolling Hills Morrow Home

7.Admission/Discharge:

  1. Primary reason for hospitalization______
  1. Reason for discharge to nursing home

□ rehabilitation□ long term care□ other ______

  1. Is this a new discharge to a nursing home?□ yes□ no
  1. Did the resident have a POLST at admission to the hospital? □ yes□ no

If the resident had a POLST at admission, was the POLST changed at discharge?  yes  no  not applicable

8. Primary service admitted to:______

Discharge Service: ______

Date of admission______Date of Discharge ______

HOSPITAL PREFERENCES, ORDERS, & LIFE-SUSTAINING TREATMENTS

9. PREFERENCES: Is there evidence of a discussion about treatment preferences in the chart at discharge: □ yes □ no

If yes, describe:

Date of Discussion / Staff involved? Identify. / Patient/family involved? Identify. / Was surrogate authorized? If so, describe role.

a. Where is this documented? ______

b. Who documented the discussion? ______

c. Length of discussion

□ 0-15 min.□ 15-30 min.□ 30-45 min□ no time listed

d. What was discussed? Please describe treatment preferences or plans.

______

  1. a.What, if any, advance directive forms are present in the chart? (Check all that apply)

Advance directive/living will (circle type used and indicate date of document)

  • LaCrosse Respecting Choices POAHC_____/_____/______Date
  • Addendum to POAHC_____/_____/______Date
  • Statement of Treatment Preference form_____/_____/______Date
  • Wisconsin Statutory POAHC_____/_____/______Date
  • Wisconsin Declaration to Physiciansor

other Living Will_____/_____/______Date

Designated Decision-maker (named by resident)_____/_____/______Date

Legal Guardian_____/_____/______Date

Other (describe) ______/_____/______Date

No form present

b. Who is making decisions at this point in time?

Patient

Healthcare Agent

Legal Guardian

Designated Decision-maker

Next of kin

Other:______

11. Document all treatment preferences in the table below.(See advance directive)

IF I AM CLOSE TO DEATH:
I want feeding tubes/artificial nutrition and hydration.
I want tube feedings only as my physician recommends
I do not want feeding tubes/artificial nutrition and hydration
No preference indicated
I want any other life support that may apply
I want life support only as my physician recommends
I want NO life support
No preference indicated / IF I AM PERMANENTLY UNCONSCIOUS/PERISTENT VEGETATIVE STATE:
I want to receive tube feeding
I want tube feeding only as my physician recommends
I do not want tube feeding
No preference indicated
I want any other life support that may apply
I want life support only as my physician recommends.
I want NO life support
No preference indicated

KIDNEY DIALYSIS

 I do want kidney dialysis
I do not want kidney dialysis
No preference indicated /

VENTILATOR SUPPORT

 I do want ventilator support
I do not want ventilator support
No preference indicated.
RESUSCITATION (preferences, not orders)
 I do want cardiac resuscitation
I do not want cardiac resuscitation
I want CPR under certain circumstances as MD recommends
No preference indicated / LOSS OF ABILITY TO RELATE TO SELF, OTHERS AND ENVIRONMENT
I do not want CPR
I do not want antibiotics
I do not want a feeding tube, artificial hydration and nutrition
No preference indicated

ANTIBIOTICS

 I do want antibiotics
I do not want antibiotics
No preference indicated /

TRANSFUSION

 I do want transfusion
I do not want transfusion
No preference indicated

PAIN AND SYMPTOM CONTROL IF EFFORTS TO PROLONG LIFE ARE STOPPED

I want to be kept comfortable even if it risks my dying sooner
No preference indicated /

HOSPITALIZATION

 I do want ______
 I do not want ______
 No preference indicated
Agent authority to admit me to a nursing home or community-based residential facility for the purpose of long-term care:
 Yes
No / Agent authority to order the withholding or withdrawal of feeding tube and IV hydration:
 Yes
No
OTHER PREFERENCES

12. ORDERS RE LIFE-SUSTAINING TREATMENT: Document all medical orders written in the medical chart in the table below.

TREATMENT CATEGORY

/

CHECK

BOX

/

WRITTEN ORDERS

/

DATE OF ORDER

Resuscitation/
Medical
Intervention / Full Code
O-DNR
O-DNR/DNI
P-DNR
Other Orders (specify)

13. TREATMENTS: Document life-sustaining treatments below.

TREATMENT PROVIDED / Date(s) of occurrences / Treatments Provided &
Other Relevant Information
Resuscitation: / 1)______
2)______
EMS visit with/without transport
(indicate treatments provided by EMS): / 1) ______
2) ______
3) ______
4) ______/ 1) ______
2) ______
3) ______
4) ______
Emergency Department Visit without hospitalization (indicate treatments provided in ED): / 1) ______
2) ______
3) ______
4) ______/ 1) ______
2) ______
3) ______
4) ______
Hospitalization: / 1) ______
2) ______
Surgery: / 1) ______
2) ______
Transfusion: / 1) ______
2) ______
3) ______
4) ______
Intubation: / 1) ______
2) ______
3) ______
4) ______
Dialysis: / 1) ______
2) ______
3) ______
4) ______
Antibiotics: / 1) ______
2) ______
3) ______
4) ______
Feeding Tubes: / 1) ______
2) ______
3) ______
4) ______
IV Fluids: / 1) ______
2) ______
3) ______
4) ______
Chemotherapy: / 1) ______
2) ______
3) ______
4) ______
Ventilator/Respirator: / 1) ______
2) ______
3) ______
4) ______

14. At discharge are there orders for life-sustaining treatment out in the community?

□ yes□ no

If yes, what type of orders?

□ Wisconsin DNR order form/bracelet_____/_____/______Date

□ POLST (Please document orders found on POLST below)

a. Is document signed? □ yes□ no

b. Is document dated?□ yes□ no

If yes, date signed:_____/_____/______Date

c. Is there a resident/surrogate signature on back? □ yes□ no

d. What parts of document have been completed?

□ A □ B□ C□ D□ E

15. POLST ORDERS AT DISCHARGE

TREATMENT CATEGORY

/

CHECK

BOX

/

WRITTEN ORDERS

/

DATE OF ORDER

A. Resuscitation / DNR/DNAR
Full Code
B. Medical Interventions / Comfort measures only….allow a natural death to occur
Do not hospitalize
Limited/advanced treatments
Full treatment
C. Antibiotics / No antibiotics
No IM/IV antibiotics
Antibiotics
D. Artificial Nutrition and Hydration / No artificial nutrition or hydration
Limited trial for _____ days
Artificial nutrition and hydration

HOSPITAL CHART REVIEW FORM: page 1

Created on10/16/2018