Stroke (CVA) Discharge Order set: SNF
Disposition:
Required: Skilled Nursing Facility Admission Orders (enter facility/agency name)
Admit to Skilled Nursing Facility:
Admit to Inpatient Rehab Facility:
Discharge Diagnosis:
MD Information:
Aftercare MD (name):
Accepting MD notified:
Condition at Discharge:
Stable
Unstable
Prognosis:
Good
Fair
Poor
Guarded
Rehab Potential:
Good
Fair
Poor
Guarded
Potential for Discharge from Nursing Home:
Potential for DC from NH in 30 Days? YES
Potential for DC from NH in 30 Days? NO
Code Status:
Code Status: Full Code
Code Status: Do Not Resuscitate / Intubate
Code Status:
Patient has Healthcare Directive
Patient has Durable Power of Attorney
Code Status discussed with:
General Orders:
PPD Given
Patient is free of communicable diseases?
Give 2-step Mantoux Test on Admission to NH
Partnering Care / NHS Orders
Partnering Care Diabetes Standing Orders
Vaccinations:
Pneumococcal Vaccine was given
Influenza Vaccine was given
Therapy Orders (type additional information in details):
PT: evaluate and treat
OT: evaluate and treat
ST: evaluate and treat
Special Instructions:
Blood glucose monitoring:
Foley (Urinary Catheter):
Medical Equipment: Type of equipment, length of need, diagnosis
Oxygen: oxygen at ___L/min, frequency (when or how to use), oxygen saturation, how long will it be needed (months/years), diagnosis
Vital signs:
IV Therapy:
Ventilator Settings: Mode_____; Rate_____; Tidal Volume______; PEEP_____; FiO2______
Other discharge instructions:
Danger signs to report:
Notify the doctor if patient experiences:
- Weakness or numbness on one body side
- Difficulty speaking, finding words, slurring, comprehending
- Severe headache
- Loss of vision, especially in one eye, double vision
- Loss of balance or dizziness
- Confusion
Review smoking cessation material (patient to follow up with primary physician)
Review and document in EPIC patient/family stroke information to include:
- Let’s talk about risk factors & stroke
- Let’s talk about ischemic stroke & their causes
- Let’s talk about high blood pressure and stroke
- Let’s talk about anti-coagulation & antiplatelet agents
- Let’s talk about lifestyle changes to prevent stroke
- Let’s talk about Stroke, TIA and warning signs
- Other: ______
Weight management: Nutrition consult
Other: ______
Activity:
Increase activity as tolerated
Activity per rehab instructions
Resume normal activities
Diet:
Regular
Cardiac (low cholesterol)
Diabetic
Renal
Tube Feeding (formula & rate)
Lab/radiology/procedures (include date and time in DETAILS for follow scheduling)
Lab tests
Radiology
Procedures
Follow up Clinic Appointments (Requires primary clinic appointment for anticoagulation follow-up)
Clinic referral: Neurology clinic 651-XXX-XXXX for follow-up of hospitalization for stroke. Appointment should be scheduled ______after discharge.
Clinic referral: Neurosurgery clinic 651-XXX-XXXX for follow-up of hospitalization for stroke. Appointment should be schedule ______after discharge.
Clinic referral: Primary Care clinic
Clinic referral:
Medication related
CORE measure: All patients with an LDL < 100 mg/dl should be prescribed a statin or fibrate OR the contraindication needs to be documented in the medical record.
CORE measure: All patient should be prescribed an antithrombotic OR the contraindication needs to be documented in the medical record.
CORE measure: All patients with hypertension should be prescribed an antihypertensive medication OR the contraindication needs to be documented in the medical record.
CORE measure: Patient’s who are a diabetic should have an A1C and follow up with their primary care clinic.
CORE measure: Patient’s who smoke should be prescribed a nicotine patch/gum/lozenge and/or prescription OR the contraindication needs to be documented in the medical record.