EmailMeForm
DISCHARGE FORM
DISCHARGE FORM
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E
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P
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Bible
HISC RN
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Please select
Francyne Felle (RN)
Alberto Melendez (RN)
Patient Name:
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Date #1 -
First day of service
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Date #2 -
Last day of service
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Date #3 -
Date deactivated from system
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Date #4 - Date of Discharge
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3 scenarios, 3 different dates for this box
1) We are told in advance of last day of service. Date = 48 hours before last day of care
2) Patient dies. Date = date we are told of death
3) We are not currently providing service, then are informed services wont continue. Date = day we are told
Date #5: Primary Care Physician was notified via fax on
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Must be within 48 hours of date #4
Make sure this is faxed with discharge date and saved in file
Reason for Discharge
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Please select
Goals Met
Patient Died
Patient/Family Request
Patient moved from Service Area
Requires care not provided by Agency
Patient Admitted to Long Term Institution
Transferred to another Agency
Admitted to Hospital
On Hold
Go to Activity section of CC for this client, look for note called Termination of Services (it is usually one of the last notes at the top)
Bottom line: if they died, chooes Patient Died. Otherwise use Goals Met
Discharge to Community to
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Please select
N/A - Patient Died
Patient able to Meet Own Needs
Hospital
Relatives Home
Congregate Care/ Adult Home / ALF
Has Formal/ Informal Help Available
To Case Management Agency
Other Home Care Agency
Instructions: if Patient died, choose N/A - Patient Died. Otherwise, choose most accurate option. Ask Staffing or Nursing Dept if unclear.
Diagnosis
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Advanced Directives
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Please select
Yes, patient had
No, patient did not have
N/A - Patient refused to provide us with information
Randomly choose 1 of the 3
Services provided
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Medication Management
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Please select
Family/ Client Responsible for Medication Management
Taken as directed
Agency was responsible for Medication Management
N/A - Patient Died
Medication list transferred
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Dont touch this
Special Needs/ Functional Limitations/ Activity Limitations/ Notes
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N/A
Dont touch this
Community Referrals Made
None
N/A - Patient Died
Home delivered meals
Adult Protective Services
Dept of Social Services/ HRA
LTHHCP/CHHA
Hospice
Other
Bottom line: if Patient died, choose N/A - Patient Died otherwise choose NONE
Method Primary Care Physician was informed
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Dont touch
RN signature
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Please select
/s/ Francyne Felle (RN)
/s/ Alberto Melendez (RN)
Choose the same RN as above
Discharge:
CC Activity Note:
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Please select
Done
Not Done
(*) Create a note in CC with Tag = "Discharge from HISC Care" and copy and paste this: Discharge form submitted.
