Download Normal Impaired F. INFECTION CONTROL ISSUES PPD Status

MEDICAL CERTIFICATION FOR MEDICAID LONG-TERM CARE SERVICES AND PATIENT TRANSFER FORM
*Patient Name:
*Last 4 SSN:
*A. PATIENT INFORMATION
*Gender: Male
Female
*Hispanic Ethnicity: Yes
No
*Race: White
Black
Other:
*Language:
English Other:
*B. SIGHT
HEARING
Normal
Deaf
Impaired
Normal Impaired
R
Hearing Aid L
Blind
C. DECISION MAKING CAPACITY (PATIENT)
Capable to make healthcare decisions Requires a surrogate
*D. EMERGENCY CONTACT
Name:
Name:
Phone:
Phone:
*E. MEDICAL CONDITION
*Primary diagnosis:
*Other diagnoses:
I. TRANSFERRED FROM
Facility Name:
Unit:
Date:
Fax:
Phone:
Discharge
Nurse:
Phone:
Discharge Date:
Admit Date:
Discharge Time:
AM PM
AM
PM
Admit Time:
J. TRANSFERRED TO
Facility Name:
Address 1:
Address 2:
Fax:
Phone:
K. PHYSICIAN CONTACTS
Primary Care Name:
Phone:
Hospitalist Name:
Phone:
L. TIME SENSITIVE CONDITION SPECIFIC INFORMATION
Medication due near time of transfer / list last time administered
Script sent for controlled substances (attached): Yes
No
PM
AM
Anticoagulants Date:
Time:
PM
AM
Antibiotics
Date:
Time:
PM
AM
Date:
Time:
Insulin
PM
AM
Other:
Date:
Time:
Has CHF diagnosis: Yes
No
If yes; new/worsened CHF present on admission?
Yes
No
Last echocardiogram: Date:
LVEF
%
On a proton pump inhibitor?
Yes
No
If yes, was it for: In-hospital prophylaxis and can be
discontinued
Specific diagnosis:
If Hospitalized:
Primary diagnosis at discharge:
Reason for transfer:
Surgical procedures performed:
F. INFECTION CONTROL ISSUES
PPD Status: Positive
Negative
Not known
Screening date:
Associated Infections/resistant organisms:
MRSA Site:
Site:
VRE
Site:
ESBL
MDRO Site:
Site:
C-Diff
Other:
Site:
Isolation Precautions:
None
Contact
Droplet
Airborne
*G. PATIENT RISK ALERTS
*None Known
*Harm to self
*Difficulty swallowing
*Seizures
*Elopement
*Harm to others
*Pressure Ulcers *Falls
*Other:
RESTRAINTS: Yes
No
Types:
Reasons for use:
ALLERGIES:
Latex Allergy:
None Known
Yes
Yes, List below:
No Dye Allergy/Reaction:
H. ADVANCE CARE PLANNING
Please ATTACH any relevant documentation:
Advance Directive
Yes
No
Living Will
Yes
No
DO NOT Resuscitate (DNR)
Yes
No
DO NOT Intubate
Yes
No
DO NOT Hospitalize
Yes
No
No Artificial Feeding
Yes
No
Hospice
Yes
No
Yes
On one or more antibiotics?
If yes, specify reason(s):
*DOB:
Yes
No
Any critical lab or diagnostic test pending
at the time of discharge?
Yes
No
If yes, please list:
M. PAIN ASSESSMENT:
Pain Level (between 0 - 10):
AM
Time:
Last administered: Date:
PM
*N. FOLLOWING REPORTS ATTACHED
No
Physicians Orders
Treatment Orders
Discharge Summary
Includes Wound Care
Medication Reconciliation
Lab reports
EKG
Discharge Medication List
X-ray
MRI
PASRR Forms
CT Scan
Social and Behavioral History
History & Physical
*ALL MEDICATIONS: (MUST ATTACH LIST)
(JUN 2016)
AHCA Form 5000-3008, ________________,
incorporated by reference in Rule 59G-1.045, F.A.C.
*Data required for Medicaid
MEDICAL CERTIFICATION FOR MEDICAID LONG-TERM CARE SERVICES AND PATIENT TRANSFER FORM
*Last 4 SSN:
*Patient Name:
O. VITAL SIGNS
Date:
Time Taken:
WT:
HT:
Temp:
BP:
HR:
RR:
*P. PATIENT HEALTH STATUS
*Bladder: Continent Incontinent
Ostomy
Catheter Type:
FEET
AM
T. SKIN CARE – STAGE & ASSESSMENT
Pressure Ulcers
(Indicate stage and location(s) of
lesions using corresponding number:
PM
INCHES
/
1.
Sp02:
2
3.
date inserted:
Foley Catheter: Yes
No If yes, date inserted:
Indications for use:
Urinary retention due to:
Monitoring intake and output
Skin Condition:
Other:
Attempt to remove catheter made in hospital?
Date Removed:
*Bowel: Continent Incontinent
Ostomy
List any other lesions or wounds:
Yes
*U. MENTAL / COGNITIVE STATUS AT TRANSFER
Alert, oriented, follows instructions
Alert, disoriented, but can follow simple instructions
No
Alert, disoriented, and cannot follow simple instructions
Not Alert
V. TREATMENT DEVICES
Heparin Lock - Date changed:
IV / PICC / Portacath Access - Date inserted:
Type:
Internal Cardiac Defibrillator
Pacemaker
Wound Vac
Other:
Respiratory - Delivery Device:
CPAP
BiPAP
Nebulizer
Other:
Nasal Cannula
Mask: Type
Oxygen - liters:
%
PRN
Continuous
Trach Size:
Type:
Ventilator Settings:
Suction
Date of Last BM:
Immunization status:
Influenza:
Yes
No Date:
Pneumococcal: Yes
No Date:
*Q. NUTRITION / HYDRATION
*Dietary Instructions:
Tube Feeding: G-tube
J-tube
PEG
Insertion Date:
Supplements (type): TPN
Other Supplements:
Self
Assistance
Difficulty Swallowing
Eating:
R. TREATMENTS AND FREQUENCY
PT - Frequency:
OT - Frequency:
Speech - Frequency:
Dialysis - Frequency:
*S. PHYSICAL FUNCTION Ambulation:
*Ambulation:
*Transfer:
Self
Not ambulatory
Assistance
Ambulates independently
1 Assistant
Ambulates with assistance
2 Assistants
Ambulates with assistive device
Devices:
Weight-bearing:
Wheelchair (type):
Left:
Appliances:
Full Partial None
Prosthesis:
Right:
Lifting Device:
Full Partial None
*Y. PHYSICIAN CERTIFICATION
W. PERSONAL ITEMS
Artificial Eye
Contacts
Eyeglasses
Dentures
U
L
Partial
Printed Name:
Rehab Potential (check one)
Good
Fair
Poor
*Physician/ARNP/PA License #:
*Date:
*Phone Number:
*Printed Physician/ARNP/PA Name & Title:
Name:
Walker
Other
Signature:
*Physician/ARNP/PA Signature:
Z.PERSON COMPLETING FORM
Prosthetic
Cane
Crutches
Hearing Aids
L
R
X. COMMENTS (Optional)
*I certify the individual requires nursing facility (NF) services.
The individual received care for this condition during hospitalization.
*I certify the individual is in need of Medicaid Waiver Services in lieu of nursing facility placement.
*Effective date of medical condition:
*DOB:
Phone Number:
(JUN 2016)
AHCA Form 5000-3008, ________________,
incorporated by reference in Rule 59G-1.045, F.A.C.
Date:
* Sections required for Medicaid