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ATP Resident Data Collection Form for Post-Discharge Evaluation Patient's Name: _______________________________ Date of ATP Visit: _____________ Medical Record Number: _______________________ Date of Birth: _________________ Date of Discharge: ____________________________ Site of Visit: __________________ PCP: ________________________________________ Discharge Diagnosis: ____________________________________________________________ Discharge Concerns: ____________________________________________________________ Examples include social support, wound management, medication compliance, etc. Problem Focused Review of Systems and Discussion of Discharge Questions: Current Functional Status: ADLs/IADLs: Physical Function: Home Health Services, including nursing and therapies (if applicable): Comment on timing from discharge to first home health visit and name of company Social Support: Medication Review ("Brown Bag Review") Compare e-discharge sheet to bottles of medications in home Identify any discrepancies in current medication regimen versus anticipated discharge regimen Objective (focus exam on systems involved in discharge diagnoses) Vitals: Temp: Pulse: BP: RR: General: O2 sat: Cardiovascular: Respiratory: Abdomen: Skin/Extremities: Neurologic: Cognitive/Affective Screening: Folstein Mini-Mental State Exam: Geriatric Depression Scale: Environmental Examination: Any potential safety hazards, concerns that could be addressed through home health, etc. Assessment of Your Discharge Plan: Comment on: - "near misses" - assessment of overall effectiveness of the transition from hospital to home -assessment of your communication with the patient and the family, both during the patient's hospital stay and during the home visit - identify at least one area of potential improvement and one area of success in your plan