PATIENT DISCHARGE. …

1 PATIENT discharge . notification /INSTRUCTIONSALTA DEL PACIENTE. NOTIFICACION/INTRUCCIONESD ischarge Date/Fecha de Alta del PacientePatient Name/Nombre de el(la) PacientePatient Record Number/N mero de Record del PacienteDear PATIENT /Estimado Paciente:It has been our pleasure to assist you during your recovery period from your recent illness, in accordance with your private physician's planof treatment and in compliance with Medicare/Medicaid guidelines, you are being discharged from all home health sido un placer asistirlo durante su periodo de recuperaci n de su reciente enfermedad. De acuerdo con el plan de tratamiento de sum dico y en cumplimiento de las regulaciones de Medicare/Medicaid, Ud. est siendo dado de alta de sus servicios de cuidado a la to follow any Diet instructions you received/Contin e las Instrucciones de Dieta Diet/Dieta Only Medications Prescribed by Your Doctor, Discard all Out-Dated Medications/Tome Solamente Medicamentos Recetadospor su Doctor, Deseche Todos los Medicamentos with the Following Treatments/Continue con los Siguientes Tratamientos:Current Treatments Include/Tratamientos Actuales with the Following Activities/Continue con las Siguientes Actividades.

2 Current Activities Include/Actividades Actuales IncluyenSpecial Precautions/Precauciones EspecialesPsychosocial Need Follow/Necesidades Psycosociales a SeguirCommunity Resource to Contact-Referrals Made/Recursos de la Comunidad para Contactar o ReferirKeep Doctor's Name and Phone Number, and Your Address Clearly Printed Next to Your Phone or On Your Name and Phone Number of Friend or Relative to Be Contacted in Case of Emergency, Next to Your Phone or On Nombre y Tel fono de Su M dico, as como su direcci n, claramente escritos Cerca de Su Tel fono o Nombre y Tel fono de un Amigo o Familiar que Pueda Ser Contactado en Caso de EmergenciaPhysician Name/Nombre del M dicoPhone Number/N mero de Tel fonoNext Physician Appointment/Pr xima CitaInstructions given to/Instrucciones dadas aRelationship to PATIENT /Relaci n con el PacienteDate/FechaPatient signature / Firma del PacienteWitness (Agency's Representative)/Testigo(Representante de la Agencia.)

3 FOR EMERGENCY CALL 911 - EN CASO DE EMERGENCIA LLAME AL 911 Date/FechaCurrent Medications IncludelMedicamentosActuales lncluyen:See current/updated medication schedule/Vea el listado de medicamentos actualizadoComment/ HOME CAREDISCHARGE IN OFFICE/AGENCYP atient s Name: _____ MR #: _____Date of discharge : _____ Report date to MD: _____Other PATIENT identifying information (Medicare, Medicaid, Insurance): _____Patient s physician and phone number: _____Patient s Status at discharge : _____Name/Title of person making report: _____Primary Diagnosis: _____Reason for discharge : 9 Dead at Home9 Move out from area of services: _____9 Transfer to an in- PATIENT facility: _____9 Other, explain: _____A brief description of why was unable to complete the discharge assessment (OASIS, ifapplicable), services provided and ongoing needs that were not met::_____Signature & Title of Staff making reportDate9 Copy faxed to PATIENT s THERAPYDISCHARGE SUMMARY ADDENDUMPoorREHAB STATUS:ExcellentFairGoodGoals documented by:DateTherapist Name/Signature/titlePATIENT NAME - Last, First, Middle InitialID#ADDITIONAL SPECIFIC THERAPY GOALS REACHEDP atient ExpectationSHORT TERMLONG TERMGait increased tinetti gait score to _____ / 12 GENERALI mproved gait requiring ____ to _____ from _____ to _____BED MOBILITYPt.

4 Able to turn side (facing up) to lateral (left/right)Pt. able to lie back downPt. able to sit up independently _____BALANCEI ncreased tinetti balance score to _____/16Pt. able to reach steady static/dynamic sitting/standing balance with/without assistanceTRANSFERPt. able to transfer from _____ to _____ with/without assistanceMUSCLE STRENGTHPt. able to hold weigh _____ lbPAINPain decreased from _____/10 to _____ /10Pt. able to oppose flexion or extension force over _____ROMPt. increased ROM of _____ by _____ degrees flexion/extensionSAFETYPt. able to use _____ independently to _____ feetPt. able to self propel wheel chair _____ feetPt able to finalize and demonstrated to follow up SURFACEPt. able to climb stair/uneven surface with/without assistance _____ steps #_____Pt. able to self repositionPHYSICAL THERAPY GOALS REACHEDDISCHARGE instructions DISCUSSED WITH: PATIENT /FamilyPhysicianOther (specify)Care ManagerOTSNSTP hysicianCARE WAS COORDINATED:Other (specify)MSWAidePTAOTHER: PATIENT DEMONSTRATED CORRECT BODY MECHANICSPATIENT AND/OR CG COMPREHEND AND DEMONSTRATEDHOME EXERCISE PROGRAMPOC (485) GOALS REACHED:DEMONSTRATED EFFECTIVE PAIN MANAGEMENTABLE TO COMPLY WITH EXERCISES: BOTH PASSIVE ANDACTIVE EXERCISE REGIMENDEMONSTRATED EFFECTIVE FALL PREVENTIONPROGRAMIMPROVED THE USE OF ASSISTIVE DEVICE: _____CARE PLAN SHORT/LONG TERM GOALS REACHED.

5 MAINTAIN/COMPLY WITH HOME SAFETY PROGRAMIMPROVED BED MOBILITY (INDEPENDENT) PATIENT EXPERIENCED A DECREASE IN PAININDEPENDENT WITH TRANSFER SKILLSPATIENT AMBULATED WITH _____ (device) FOR _____ FT WITH _____ ASSISTINCREASED STRENGTH OF RUE LUE RLE LLE TO ALLOW PATIENT TO PERFORM THE FOLLOWING ACTIVITIES: RANGE OF MOTION (ROM) OF _____ JOINT TO _____ DEGREE FLEXION AND _____ DEGREE EXTENSION IN ____ WEEKS TO ALLOW PATIENT TO PERFORM THE FOLLOWING ACTIVITY: TO REMAIN IN HOME/RESIDENCE/ALF WITH ASSISTANCE OF PRIMARY CAEGIVER/SUPPORT AT HOMEABLE TO UNDERSTAND MEDICATION REGIMEN, AND CARE RELATED TO HIS/HER : MAXIMUM FUNCTIONAL POTENTIAL TO UNDERSTAND MEDICATION REGIME AND CARE RELATED TO DISEASEDISCHARGED: MAXIMUM FUNCTIONAL POTENTIAL REACHEDDISCHARGED: PATIENT AND/OR CAREGIVER IS/ARE ABLE TO DEMONSTRATE KNOWLEDGEOF DISEASE MANAGEMENT, S/S IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HIS/HER CURRENT LIMITATION AT TO INDEPENDENT LEVEL OF SELF TO REMAIN SAFELY IN RESIDENCE WITH ASSISTANT OF THERAPYDISCHARGE SUMMARY ADDENDUMPoorREHAB STATUS:ExcellentFairGoodGoals documented by:DateTherapist Name/Signature/titlePATIENT NAME - Last, First, Middle InitialID#ADDITIONAL SPECIFIC OT GOALS REACHEDP atient ExpectationSHORT TERMLONG TERMPain level decreased from ___/10 to ___/10Pt.

6 Able to stand in kitchen to prepare meal for ____ minOCCUPATIONAL THERAPY GOALS REACHEDDISCHARGE instructions DISCUSSED WITH: PATIENT /FamilyPhysicianOther (specify)Care ManagerPTSNSTP hysicianCARE WAS COORDINATED:Other (specify)MSWAideOTAOTHER: PATIENT DEMONSTRATED IMPROVEMENT IN COPING IN ADL'S, IADL' AND/OR CG COMPREHEND AND DEMONSTRATEDHOME EXERCISE PROGRAMPOC (485) GOALS REACHED:DEMONSTRATED PROPER USE OF PROSTHESIS/BRACE/SPLINTDEMONSTRATED PROPER USE OF EFFECTIVE FALL PREVENTION PROGRAMIMPROVED THE USE OF ORTHOTIC, SPLINTING AND/OR EQUIPMENT, ASSISTIVE DEVICE: _____CARE PLAN SHORT/LONG TERM GOALS REACHED:MAINTAIN/COMPLY WITH HOME SAFETY PROGRAMPATIENT DEMONSTRATED IMPROVEMENT IN COPING IN MUSCLE USE, MOTOR COORDINATIONINCREASED STRENGTH OF RUE LUE RLE LLE TO ALLOW PATIENT TO PERFORM THE FOLLOWING ACTIVITIES: DEMONSTRATED IMPROVEMENT IN COPING IN NEURO RESPONSEABLE TO REMAIN IN HOME/RESIDENCE/ALF WITH ASSISTANCE OF PRIMARY CAEGIVER/SUPPORT AT HOMEABLE TO UNDERSTAND MEDICATION REGIMEN, AND CARE RELATED TO HIS/HER : MAXIMUM FUNCTIONAL POTENTIAL TO UNDERSTAND MEDICATION REGIME AND CARE RELATED TO DISEASEDISCHARGED: MAXIMUM FUNCTIONAL POTENTIAL REACHEDDISCHARGED.

7 PATIENT AND/OR CAREGIVER IS/ARE ABLE TO DEMONSTRATE KNOWLEDGEOF DISEASE MANAGEMENT, S/S IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HIS/HER CURRENT LIMITATION AT TO INDEPENDENT LEVEL OF SELF TO REMAIN SAFELY IN RESIDENCE WITH ASSISTANT OF PLANNED DISCUSSED WITH PATIENT / FAMILYP atient able to reach _____ on _____ PATIENT able to lift _____ # pounds from _____ to _____Patient able to wash _____Patient able to reach a Cup from _____ and taked to _____Patient able to integrate orthotic/prosthetic _____ to _____Patient independent with safety issues inImproved bathing skills, use toPatient retraining of cognitive, feeding, and perceptual skillsPatient able to improve body image withIndependent with muscle re-educationOTHER: PATIENT able to finalize and demonstrate to follow up HandsIncreased strengthRIncrease Neuro response byUse of SPLINTING AND/OR EQUIPMENT independentL Hands Increased coordinationRDemonstrate Hands motion to WNL withinL Hands Increased sensationRUNLIMITED HOME CARE, HOME CARED ischarge letter notification to PATIENT /Family(Spanish Translation in the Back)Dear: _____Please be advised that as of _____/_____/_____you have been discharged from our HomeHealth Care Agency.

8 We have mailed you final discharge summary to your physician. We hope that your care was of a more than satisfactory nature. Please complete the PatientSurvey that is included in your PATIENT package and return mail it to wish you will continue with good health. Please remember to take your medications asprescribed by your physician and to follow-up visit your visit your physician per his/her call us should you need further or additional ,_____Director of Nursing or Qualified SAMPLEC arta de Informaci n de Alta al Paciente/Famil aPor favor, usted est siendo avisado(a) de que en la siguiente fecha ____/____/____ ser dadode alta de nuestra Agencia de Cuidados de Salud en el Hogar. Nosotros le hemos enviado porcorreo a su m dico el sumario de su alta que su cuidado haya sido m s que satisfactorio. Por favor complete la Encuestadel Paciente incluido en los papeles dejados en su casa y retornarlo por correo a deseamos que usted contin e con buena salud.

9 Por favor, recuerde tomar susmedicamentos como han sido prescritos por su doctor y seguir todas las indicaciones de favor, ll menos si usted necesitara asistencia SAMPLE