Required: Skilled Nursing Facility Admission Orders (Enter Facility/Agency Name)

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): c PT: evaluate and treat c OT: evaluate and treat c ST: evaluate and treat

Special Instructions: c Blood glucose monitoring: c Foley (Urinary Catheter): c Medical Equipment: Type of equipment, length of need, diagnosis c Oxygen: oxygen at ___L/min, frequency (when or how to use), oxygen saturation, how long will it be needed (months/years), diagnosis c Vital signs: c IV Therapy: c Ventilator Settings: Mode_____; Rate_____; Tidal Volume______; PEEP_____; FiO2______c Other discharge instructions:

Danger signs to report: c 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 c Review smoking cessation material (patient to follow up with primary physician) c 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: ______c Weight management: Nutrition consult c Other: ______Activity: c Increase activity as tolerated c Activity per rehab instructions c 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) c Lab tests c Radiology c Procedures

Follow up Clinic Appointments (Requires primary clinic appointment for anticoagulation follow-up) c Clinic referral: Neurology clinic 651-XXX-XXXX for follow-up of hospitalization for stroke. Appointment should be scheduled ______after discharge. c Clinic referral: Neurosurgery clinic 651-XXX-XXXX for follow-up of hospitalization for stroke. Appointment should be schedule ______after discharge. c Clinic referral: Primary Care clinic c 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.