Escolar Documentos
Profissional Documentos
Cultura Documentos
Instructions: Discharge Planning begins on the first day of patient /resident admission. Please complete and fax this form beginning with admission and with each update thru discharge. If no change occurs by discharge, resubmit with a signature and date at the bottom of the second page, indicating no change
Patient Information:
Patient Name DOB ID #
Phone #
Discharging Facility:
Name of Discharging Facility Facility DC Planner Patient Anticipated DC Date Prior living situation
____ 2 Story ____ #Steps within Home OT OT ____Ranch ____ Bed/Bath Level Community Resources: ______________________________ Acute Hospital Care Other
Home:
Facility / Home Care Agency (HCA) / Hospice Name Name of Home Care Agency Case Manager Phone #
Contact name
Phone #
Wheel Chair Walker (type) _______ Cane Reachers Sock Aid Ramp Elevated Toilet Seat Safety Rails Other None Required
Page 2 of 3
Patient Name DOB ID #
Significant Other Guardian Sibling Primary Caregiver Lives Alone Spouse Neighbor Information: Daughter/Son Other Family Friend Availability for Physical Assist:_________________________
Relationship to Patient/ Family (Please choose from options Lives Alone Spouse Significant Other Guardian Sibling Able to handle care needs
Additional Caregiver Daughter/Son Other Family Friend Neighbor Information: Availability for Physical Assist:_________________________
Caregiver Name Address City
Phone #
Are there any caregiver issues that we should be aware of to better assist patient? Yes No If yes, please describe below:
Current Patient Alert Oriented Cooperative Psycho-Social and Mental Status: Depression Screen/Mini Mental?
Describe needs: Is Patient Safe to return home?
Agitated No No Assist
Independent
Full Assist
Page 3 of 3:
Patient Name DOB ID #
Durable Power of Attorney Durable Power of Attorney/ Health Care Attorney DPOA Name DPOA/HC Name
Phone # Phone #
Financial Planning:
Secondary Insurance
Prior to discharge please schedule a follow up doctor appointment for within 30 days of discharge.
Are there any barriers to patient following up with appointment? Yes No Please describe:______________________________________________________