Download ATP Resident Data Collection Form for Post

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