Readmission Assessment Tool Current Admit Date: _______ Readmit from _________________________________ Previous admit dates: ___________________ (Home, ALF, ECF, SNF, Rehab, Home w/ Home Health…) Name of Facility if applicable____________________________ Diagnosis for previous Admission____________________ Diagnosis for Readmit_________________ Was the d/c follow up appointment made at discharge? Yes No Was the d/c follow up appointment made by the patient? Yes No Weekend/Evening Date of f/u appointment: ____________________(Days after d/c)_______________________ Did the patient go to the appointment? Yes No Were there new medications prescribed at discharge? Yes No If there were new medications, were they filled and being taken correctly? Readmit before appt. Yes No N/A Did the patient receive and understand the medications prescribed at d/c? Yes No If not, why? _________________________________________________________________________ (Confusion, expense, misunderstanding of instructions, travel, etc…) Did the patient discharge home with HHC, SNF, ALF? Yes No N/A Was HHC, SNF, or an ALF offered? Yes No N/A Did the patient refuse HHC, SNF or ALF? Yes No N/A Are HHC, SNF or ALF appropriate for discharge of this admission? Yes No (Ask patient) Is there anything different that you feel we could have done to prevent your readmission? ______________________________________________________________________ Was the discharge plan appropriate? Yes No Other ideas: ________________________________________________________________________ Community Care Navigator involvement first admission? Yes No Was pt. appropriate for Palliative Care Consult last admission? Yes No Was Palliative Care Consult order requested this readmission? Yes No Person Completing:____________________ Revised: 4/16/14 Patient Label: N/A Mercy Hospital Ft. Scott DISCHARGE CHECKLIST / CORE MEASURE CHECKLIST ACUTE CARE (Swing Bed not included in Core Measures. GO TO Pg 2 for SWB discharges) Place Patient Sticker Here ALL Discharges: AMI: Room: _____ Priority/Anticipated D/C time: ___________ Discharge date: ___________ Complete this form for ALL ACUTE CARE DISCHARGES Flu vaccine administered -OR – pt refusal / vaccine date for current flu season documented (if criteria) Pneumonia vaccine administered - OR- pt refusal / vaccine date documented (if criteria met) VTE prophylaxis (mechanical or pharmacologic) received, patient refusal documented, or reason not ordered is documented (or cosigned) by prescriber within 24 hours of admission. Tobacco / Substance abuse cessation education Aspirin ordered at arrival or refusal / contraindication documented Aspirin ordered at discharge or refusal / contraindication documented Beta-blocker ordered at discharge or refusal / contraindication documented ACEi or ARB oredered at discharge If LVSD present (EF < 40%) or refusal / contraindication documented Statin at discharge if LDL >= 100 w/in 24 hrs after or 30 days prior to arrival or refusal / contra documented CHF or Hx of CHF: 2D Echo – Was one completed this hospitalization? o If prior to hospital, documented date completed and EF%, report copy scanned o If none prior and none during this encounter, MUST BE SCHEDULED to occur after discharge ACEi or ARB at discharge -- IF LVSD present (EF < 40% on ECHO) or refusal / contra documented AVS includes: Activity, SCHEDULED follow-up appt, diet, S/S of worsening, weight monitoring, ALL discharge medications listed as appearing in discharge summary PNEUMONIA: Blood cultures prior to antibiotic (ALL ICU patients and only IF ordered in non-ICU pt) SURGICAL: (Hysterectomy, Hip/Knee, Colon surgeries) Surgery date & end time:_____________________ Beta Blocker – IF ON BB prior to arrival -- BB given prior to surgery and throughout hospital stay or documented contraindication Prophylactic antibiotic infusion start time w/in 1 hour prior incision time or 2 hrs for Vanco Prophylactic abx d/c’d w/in 24 hrs of surgery end time or documentation by physician of possible or suspected infection. VTE prophylaxis (GYN & Urologic surgeries only require mechanical) o Pharmacologic ordered and given w/in 24 hrs of surgery end time o Mechanical ordered on all surgical pts w/in 24 hours of admission if no pharmacologic Foley removed by post-op day 2 or physician documented reason for continued use CONFIRMED DVT: If IV Heparin given, dosing and platelet monitoring per protocol If warfarin (Coumadin) ordered: o Overlap of parenteral anticoagulant for min of 5 days AND INR 2 or greater x 2 consecutive days – or documentation of APPROVED reason for gap in overlap coverage o Parenteral anticoagulant prescribed at discharge if above criteria unmet Anticoagulant education/counseling provided & documented for anticoagulants ordered AVS includes: Education regarding compliance, dietary advice, F/U monitoring (next INR), potential for adverse drug reactions & interactions for warfarin if ordered at discharge ISCHEMIC STROKE: Antithrombotic therapy (antiplatelet / anticoag) ordered by hospital day 2 AND at discharge Anticoagulant therapy for A-Fib/Flutter ordered at discharge Statin ordered at discharge if LDL >= 100 w/in 48 hrs after or 30 days prior to arrival or if was on prior to hospitalization Pt refusal / contraindication documented if any of above not ordered HEMORRHAGIC & ISCHEMIC STROKE: Assessed for Rehab AVS includes: Education on activation of EMS, stroke risk factors, S/S of stroke, F/U appt date, ALL discharge medications All elements should be fixed BEFORE discharge! Fix or complete any nursing documentation or interventions required. If needed, call the physician to get any needed orders. If physician does not want this for the patient, remind him/her to document contraindication in D/C Summary and document the conversation as a nursing communication. _____________________________ ALL DISCHARGES TO HOME:_(Swingbed and Acute Care)____________ Dr Completed Medication Reconciliation Pharmacy Contacted Discharge Instructions Complete Additional Educational Handouts Return Appointment Made Prescriptions Printed/Signed OR E-prescribed Important Message from Medicare AVS Signed & Dated & Copy given to patient Core Measure Met Social Services Consult: o Home Health o Equipment Received Call Back on Pharmacy Review Own / Relabeled / OTC Meds Sent with Patient Server Cleaned & Meds Returned/Discarded Notify Family if Not Present ALL DISCHARGES TO NURSING HOME:_(Swingbed and Acute Care)__ _____________________ Dr Completed Medication Reconciliation Pharmacy Contacted Acute Care Transfer Print Transfer Packet Call Report Discharge Instructions Complete Additional Educational Handouts Return Appointment Made Important Message From Medicare Core Measure Met Social Service Consult Care Assessment Received Call Back on Pharmacy Review TB Skin Test if New to Nursing Home, w/ date to Read Notify Family If Not Present Own / Relabeled / OTC Meds Sent with Patient Completed AVS, signed by D/C physician for N.H. orders Copy of signed orders put in paper lite chart (original with patient to Nursing Home Server Cleaned & Meds Returned / Discarded Policy: All discharges will have this form signed by the house supervisor. This includes acute care discharges (no SWBs) from M/S, ICU, and OB if surgical patients. This form needs to be completed prior to the patient’s discharge so that any intervention needed to complete the core measure will be completed prior to the patient leaving the building. These forms will be turned in to Nursing Administration daily for tabulation and analysis. Nursing Supervisor Signature: ___________________ ________Core Measures Completed: NOT PART OF THE MEDICAL RECORD – DO NOT SCAN INTO EPIC Revised 8/22/13 Yes No N/A TARGET WEIGHT: _____________________ Month: _______________ Day Weight 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Mercy Heart Failure Blood Swelling? Shortness Pressure Feet/Ankles/Stomach of breath? & Pulse New? The Same? More? New? The Same? More? Fluid Intake Daily Heart Log Diet Comments Tired? Confusion? KNOW THE WARNING SIGNS OF WORSENING HEART FAILURE All Right      No weight gain of more than 2 pounds in 24 hours No swelling in your feet, ankles, or stomach No shortness of breath No increased weakness or feeling tired No persistent cough • Weigh yourself every day; at the same time and the same scale. • Take all medications as prescribed by your physician. • Check your feet, ankles, and stomach daily for swelling. • Eat low salt foods • Balance activity and rest throughout your day. Caution      Weight gain of 3 or more pounds in one day or a weight gain of 5 pounds in 2 or more days/week More swelling in your feet, ankles, or stomach More shortness of breath; hard time lying flat in bed or needing to sleep in a chair at night Feeling tired or more weak than usual Persistent productive cough with phlegm or dry hacking cough CALL DR. ____________________________________ AT #___________________________ Seek Immediate Help! Above Caution signs and…  Difficulty breathing while at rest  Chest pain  Unable to think clearly, confusion GO TO THE CLOSEST EMERGENCY ROOM OR CALL 911