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Discharge Planning Assessment

Home Discharge Planning Assessment
Where is the information obtained from?
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1. NEUROLOGICAL STATUS

What is the Neurological Status of the patient?
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Enter any comments for Section 1 Neurological Status
let us know your comments for this section
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2. ADVANCED DIRECTIVES

Does the Patient have Advanced Directives on File?
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Enter any comments for Section 2 Advanced Directives
let us know your comments for this section
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3. EMERGENCY CONTACT

Does the patient have an Emergency Contact?
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What is the Patients Relationship to the Emergency Contact?
  • - select a relationship-
  • Spouse
  • Mother
  • Father
  • Brother
  • Sister
  • Neighbor
  • Other
- select a relationship-
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If other relationship to Emergency Contact above
Patients Emergency Contact Relationship
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Emergency Contact First Name
Contact First Name
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Emergency Contact Last Name
Contact Last Name
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Emergency Contact Phone Number
Emergency Contact Phone Number
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Enter any comments for Section 3 Emergency Contact
let us know your comments for this section
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4. VETERAN SERVICES

Is the Patient a Veteran
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IF Yes, Are they Connected with VA Services
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IF YES, was UM Department Notified?
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IF YES, was RN Case Manager at Northport VA Medical Center Notified?
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IF YES, Was the Department of Veterans Affairs notified on 72 Hours Notification Hotline?
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Enter any comments for Section 4 Veterans Services
let us know your comments for this section
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5. DEMOGRAPHICS

Where does the patient currently live or reside?
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HOME

IF patient lives at home who do they live with
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IF they live with someone who do they live with?
Who do they lived with?
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How many steps are there to enter in front of the house?
  • - select # steps -
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
- select # steps -
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How many steps are there to enter Bedroom
  • - select # steps -
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
- select # steps -
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APARTMENT

If patient lives in an Apartment who do they lives with
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IF they live live in an APT with someone who do they live with?
Who do they lived with?
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Does the apartment have an elevator?
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If no elevator how many flights of stairs is the walk up
  • - select # flights-
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
- select # flights-
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SAR/NH FACILITY

Select the SAR/NH Facility the Patient is coming from
  • - Select the SAR/NH Facility the Patient is coming from -
  • Our Lady of Consolation
  • Carillon Nursing & Rehab Center
  • Apex Rehab & Care
  • Berkshire Nursing Center
  • Hilaire Rehab & Nursing
  • East Neck Nursing & Rehab Center
  • Huntington Hills Center for Health & Rehab
  • Hampton Center Rehab Nursing
  • Broadlawn Manor Nursing & Rehab Center
  • San Simeon By the Sound
  • Gurwin Jewish Nursing & Rehab Center
  • Veterans Affairs Medical Center
  • Sunrise Manor Center for Nursing
  • Maria Regina Residence
  • Ross Center for Health & Rehabilitation
  • Momentum at South Bay
  • St. Johnland Nursing Home
  • St. Catherine of Siena Nursing and Rehabilitation Care Center
  • Avalon Gardens Nursing & Rehab
  • Peconic Bay Skilled Nursing Facility
  • Westhampton Care Center
  • Affinity Skilled Living
  • Riverhead Care Center
  • Smithtown Center for Rehab
  • Nesconset Center for Nursing & Rehab
  • Sayville Nursing & Rehab Center
  • Mills Pond Nursing & Rehab Center
  • St. James Rehabilitation & Healthcare Center
  • Oasis Rehabilitation & Nursing
  • Long Island State Veterans Home
  • Suffolk Center
  • Bellhaven Center for Rehab & Nursing Care
  • Port Jefferson Health Care
  • Jefferson Ferry Lifecare Retirement Community
  • Brookhaven Health Care Facility
  • Island Nursing & Rehab Center
  • Woodhaven Nursing Home
  • Medford Multicare Center for Living
  • Lakeview Rehab & Care Center
  • Oak Hollow Nursing Center
  • Massapequa Center Rehab & Nursing
  • Other
- Select the SAR/NH Facility the Patient is coming from -
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If SAR/NH Facility not listed above, please enter name here
Name of SAR/NH Facility not listed above
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Enter Details or Facility Not Listed Above
Enter Details of Facility Not Listed Above
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Enter any comments for Section 5 Demographics
let us know your comments for this section
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6. FACESHEET

Does the facesheet have an updated address
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If facesheet didn't have an updated address did you notify registration?
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Does the Facesheet have updated contact information
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If facesheet didn't have updated contact information did you notify registration?
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Enter any comments for Section 6 Facesheet
let us know your comments for this section
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7. FUNCTIONAL STATUS

Functional Status
Choose the patients functional needs
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Enter any comments for Section 7 Functional Status
let us know your comments for this section
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8. DME's PRIOR TO ARRIVAL

Patients DME's Prior to Arrival
Choose the patients functional needs
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If the patient has other DME's describe here
Tell us about other DME\'s
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Enter any comments for Section 8 DME's
let us know your comments for this section
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9. TRANSPORTATION

Patients Mode of Transportation
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If unable to drive who is transportation provided by
Enter Text Here
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Enter any comments for Section 9 Transportation
let us know your comments for this section
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10. PCP NOTIFICATION FORM

Does the patient have a Primary Care Physician?
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PCP Notification Form Completed?
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Enter any comments for Section 10 PCP Notification Form
let us know your comments for this section
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11. PREVIOUS OUTPATIENT SERVICES

Does Patient have previous Outpatient Services?
If yes, select and if other please explain in the text box
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Other Previous Outpatient Services
Describe the other outpatient services not listed above
Enter Text Here
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Enter any comments for Section 11 Previous Outpatient Services
let us know your comments for this section
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12. CURRENT SERVICES

Current Services
If yes, select and if other please explain in the text box
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Other Current Outpatient Services
Describe the Current Outpatient Services
Enter Text Here
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Enter any comments for Section 12 Current Outpatient Services
let us know your comments for this section
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13. PHARMACY

Which Pharmacy does the patient use?
Please enter name and town of the pharmacy
Type the name and town of patients pharmacy
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Enter any comments for Section 13 Pharmacy
let us know your comments for this section
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14. CAREGIVER

Who is the patients primary care giver?
Please enter the patients primary care giver if any and their relationship
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Enter any comments for Section 14 Caregiver
let us know your comments for this section
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15. CONSULTS

Was Social Work Consulted?
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Enter any comments for Section 15 Consults
let us know your comments for this section
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16. ANTICIPATED DISCHARGE PLAN

Anticipated Discharge Plan
Detail the anticipated discharge plan here
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Enter any comments for Section 16 Anticipated Discharge Plan
let us know your comments for this section
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17. FINAL DISCHARGE PLAN

Discharge home with
Select discharge plan
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Enter any comments for Section 17 Final Discharge Plan
let us know your comments for this section
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18 PERTINENT DISCHARGE INFORMATION

Pertinent Discharge Information
Describe other pertinent discharge information here
Enter Text Here
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Other Discharge Plans
Describe other discharge plans not listed above
Enter Text Here
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Enter any comments for Section 18 Pertinent Discharge Info
let us know your comments for this section
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