Nursing Home to Hospital Transfer Form

Resident Name: (last, first, middle initial) Language: ¨ English ¨ Other: Resident is: ¨ SNF/Rehab ¨ Long-term Date Admitted: (most recent) / / DOB: / / Primary Diagnosis(es) for admission: Code Status: ¨ Full Code ¨ DNR ¨ DNI ¨ DNH ¨ Comfort Care Only ¨ Uncertain ¨ Hospice

Attending Physician in Nursing Home: ¨ MD ¨ NP ¨ PA Who to Call at the Nursing Home to Get Questions Answered: Name: Name/Title: Tel: ( ) Tel: ( )

Key Clinical Information: Reason for Transfer: Tests: Relevant Diagnoses: ¨ CHF ¨ COPD ¨ CRF ¨ DM ¨ Ca (active treatment) ¨ Dementia ¨ Other: Vital Signs: BP HR RR Temp O2 Sat Time taken (am/pm) Most Recent Pain Level (¨ N/A) Pain location: Most Recent Pain Med Date given: / / Time (am/pm)

Usual Mental Status: Usual Functional Status: ¨ Alert, oriented, follows instructions ¨ Ambulates independently ¨ Alert, disoriented, but can follow simple instructions ¨ Ambulates with assistive device ¨ Alert, disoriented, but can not follow simple instructions ¨ Ambulates only with human assistance ¨ Not Alert ¨ Not ambulatory

Devices and Treatments: Isolation Precautions: Allergies: ¨ Supplemental Oxygen ¨ MRSA ¨ VRE ¨ Pacemaker Site: ¨ Internal Defibrillator ¨ C. difficile ¨ Norovirus ¨ Hip/Joint Replacement ¨ Respiratory Virus or Flu ¨ Needs Mask ¨ Other: ¨ Other:

Risk Alerts: Personal Belongings Sent with Resident: ¨ Falls ¨ Pressure Ulcer(s) ¨ Eyeglasses ¨ Jewelry ¨ Aspiration ¨ Seizures ¨ Hearing Aid ¨ Dental Appliance ¨ Harm to self or others ¨ Limited/Non weight bearing: ( ¨ left ¨ right) ¨ Other: ¨ Wanderer ¨ Other:

Treatments and Frequency (include special treatments such as dialysis, Diet: chemotherapy, transfusions, radiation, TPN): Needs assistance with feeding? ¨ No ¨ Yes Trouble Swallowing? ¨ No ¨ Yes Special Consistency (thickened liquid, crushed meds, etc.) ¨ No ¨ Yes TPN ¨ No ¨ Yes Enteral Tube Feeding? ¨ No ¨ Yes (formula/rate)

Skin/Wound Care (pressure ulcer stage, location, Immunizations: Impairments-General: appearance, treatments): ¨ Influenza (date / / ) ¨ Cognitive ¨ Vision ¨ Pneumococcal (date / / ) ¨ Speech ¨ Hearing ¨ Wound form attached (if applicable) ¨ Tetanus Vaccine (date / / ) ¨ Sensation ¨ Other:

Additional Relevant Information:

Form Completed By: (name/title) Signature If this page is sent after initial transfer: Date sent / / Time (am/pm) Hospital to Nursing Home Transfer Form

Patient Information Sticker: Advance Directives/Goals of Care ¨ Full Code ¨ DNR (Do Not Resuscitate) ¨ DNI (Do Not Intubate) ¨ DNH (Do Not Hospitalize) ¨ No Artificial Feeding ¨ Comfort Care ¨ Hospice Care ¨ Other (specify): Were goals of care discussed during this hospitalization? ¨ No ¨ Yes (specify) Post-Acute Care Information

Transferred to: Tel: ( ) Patient decision making capacity? ¨ ¨ Nurse to Nurse Verbal Report? No Yes (specify to whom) ¨ Capable of making decisions ¨ Requires proxy Receiving and Attending Physician:

High Risk Condition/Treatment Information (check all that apply) ¨ Fall Risk: Precautions: ¨ Heart Failure: ¨ New Diagnosis? ¨ Exacerbation this admission? Date of last echo: / / ¨ EF: % Dry Weight (if known): ¨ Anticoagulated: Reason: ¨ Afib ¨ DVT/PE ¨ Mech. Valve ¨ Post-OP ¨ Low EF ¨ Other: Duration Goal INR: ¨ 1.5 – 2.5 ¨ 2 – 3 ¨ Other: ¨ On PPI: Indication(s): ¨ In-Hospital prophylaxis and can be d/c ¨ Specific DX: ¨ On Antibiotics: Indication(s): Total treatment course days Date Started: / / ¨ Diabetic: Most recent glucose Date: / / Time (am/pm): (please attach list of recent values if available)

Procedures and Key Findings (during this hospitalization) Medications and Allergies List Procedures (surgeries, imaging): ¨ Medication list must be attached ¨ Please provide a hard copy prescription written for a 1–3 day supply for controlled substances. Key Findings: Allergies: ¨ None Known ¨ Yes (specify): Pain Med: ¨ No ¨ Yes (specify): Dose: ¨ Reports must be attached Last Dose (am/pm):

Physical and Sensory Function Ambulation: ¨ Independent ¨ With Assistance ¨ With Assistive Device ¨ Not Ambulatory Weight Bearing: ¨ Full ¨ Partial L/R ¨ None L/R Transfer: ¨ Self ¨ 1-Person Assist ¨ 2-Person Assist Devices: ¨ Wheelchair ¨ Walker ¨ Cane ¨ Crutches ¨ Prosthesis ¨ Glasses ¨ Contacts ¨ Dentures Hearing Aid: ¨ Left ¨ Right Continence: ¨ Continent ¨ Bladder Incontinent ¨ Catheter Date Inserted: / / Reason For Catheter: ¨ Retention ¨ Skin Protection ¨ Other (specify): ¨ Bowel Incontinent ¨ Ostomy ¨ Date of last BM: / / Sensory Function: Sight: ¨ Normal ¨ Impaired ¨ Blind Hearing: ¨ Normal ¨ Impaired ¨ Deaf

Nutrition and Hydration Diet: Consistency: Free Water Restriction: Tube Feeding: ¨ G-Tube ¨ J-Tube Date Inserted: / / F Free Water Bolus: cc every: hrs Artificial Nutrition: ¨ TPN ¨ Tube feed product: Rate: cc/h Duration: h/day

Treatments and Therapeutic Devices Vascular Access: ¨ Date Inserted: / / (please attach imaging report confirming placement) Cardiac: ¨ Pacemaker ¨ ICD ¨ Other (specify): Respiratory: ¨ CPAP ¨ BiPAP ¨ O2 L ¨ prn ¨ Continuous ¨ Suction ¨ Trach Size:

Therapies (please attach assessment/recommendation) ¨ Physical Therapy ¨ Occupational Therapy ¨ Speech Therapy ¨ Respiratory Therapy ¨ Hand Held Nebulizer ¨ Dialysis Hospital to Nursing Home Transfer Form (cont’d)

Skin/Wound Care (pressure ulcer stage, location, Risks and Precautions (check all that apply) appearance, treatments): ¨ Fall ¨ Delirium ¨ Agitation ¨ Aggression ¨ Wandering ¨ Aspiration ¨ Other: ¨ Wound form attached (if applicable) Precautions:

Infection Control Issues Infection/Colonization: ¨ MRSA ¨ VRE ¨ C. difficle ¨ ESBL ¨ Flu ¨ Other: Isolation Precautions: ¨ None ¨ Contact ¨ Contact-Plus ¨ Droplet ¨ Airborne Immunizations: ¨ Influenza: ¨ No ¨ Yes: / / ¨ Pneumococcal: ¨ No ¨ Yes: / /

Critical Transitional Care Information: Pending Tests and Follow Up Summarize high-priority care needs for the next 24–48 hours (including essential medications, pain control, tests needed, follow-up)

Pending Lab and Tests Results:

Recommended Follow Up Tests, Procedures, Appointments:

Personal Belongings Sent with Resident: ¨ Eyeglasses ¨ Jewelry ¨ Hearing Aid ¨ Dental Appliance ¨ Other:

Form Completed By: (name/title) Signature If this page is sent after initial transfer: Date sent / / Time (am/pm) Transfer Checklist

Resident Name: (last, first, middle initial)

Facility Name: Tel ( )

Copies of Documents Sent with Resident (check all that apply)

Documents recommended to accompany resident: Resident Transfer Form

Face Sheet

Current Medication List or Current MAR

SBAR and/or other Change in Condition

Advance Care Orders (POLST, MOLST, POST, others)

Advance Directives (Durable Power of Attorney for Health Care, Living Will)

Send these documents if indicated: Recent Hospital Discharge Summary

Relevant Lab Results

Relevant X-Rays and other Diagnostic Test Results

Ambulance Driver Signature: (required) Ambulance driver is responsible for delivering transfer packet to personnel at receiving facility.