FINAL UPTF Hospital to PAC



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|HOSPITAL LOGO |

PENNSYLVANIA PATIENT TRANSFER

TO POST ACUTE CARE FORM

(please type or print legibly)

Date & Time ___________________ Patient Name: (Last, First, MI) ___________________________________________________

Date of Birth: (mm/dd/yy) _____________ Gender: ☐ M ☐ F Code Status: ☐ Full ☐ DNR ☐ DNI ☐ POLST

☐ Out-of-Hospital DNR attached

|Vital Signs: T_______ P______ R_______ BP________ O2 Sat%__________ Height________ Weight__________ |

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|Preferred Language: ☐ English ☐ Other _____________ Race: ________________ Ethnicity: __________________________ |

|Patient Representative: _________________________________ Relationship: Spouse/Child/Other _________________________ |

|Patient Representative Phone:(Day)__________________(Night)__________________(Cell)________________________________ |

Reason for Hospitalization _____________________________________________________________________________________

____________________________________________________________________________________________________________

Type of Hospital Stay: __ Observation Stay __ER Visit __ Inpatient Admission Dates of Stay _____________ to _____________

Hospital Primary Physician/Practitioner: __________________________________________________________________________

Transferring Hospital Contact Name and Number: _____________________________________________ Title: _______________

Transferred to: __ NF __ ALR __PCH

Type of Transfer/Admission: __ Transfer/Readmission ___ New Admission

Type of Care: __ Short-term Rehabilitation __ Long-term Placement __ Hospice/Palliative Care

Transferred To: ____________________________________ Receiving Facility Contact: ___________________________________

Direct Number: _______________________________________ Title: ___________________________________________________

Pre-Discharge Preparation and Treatments at the Hospital: __________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Primary and Secondary Diagnosis: _______________________________________________________________________________

Target Diagnosis (Mental Health/Intellectual Disability/Other Related Conditions): ________________________________________

______________________________________________________________________________________________________________

Psychosocial Behavioral History: _________________________________________________________________________________

______________________________________________________________________________________________________________

PASRR Level I Completed __Yes __ No

PASRR Level II Required __ Yes __No PASRR Level II Completed __Yes __No

Exempt Hospital Discharge __Yes __ No

Target Letter Obtained and Attached _____

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Allergies: (medication, food, insect, material) ☐ NKA ☐ Yes List: __________________________________________________________

Cognitive Behavioral Status: ☐ Alert ☐ Oriented Times_____________ ☐ Combative ☐ Restraints

☐ Disoriented ☐ Forgetful ☐ Depressed ☐ Anxious ☐ Unresponsive ☐ Intellectual Disability

At Risk Alerts: ☐ Fall ☐ Seizure ☐ Pressure Ulcer ☐ Aspiration ☐ Wander ☐ Elopement Harm to: ☐ Self ☐ Others

Sensory: Vision: ☐ Good ☐ Poor ☐ Blind ☐ Glasses Hearing: ☐ Good ☐ Poor ☐ Deaf Hearing Aid ☐ R ☐ L

Speech: ☐ Clear ☐ Difficult ☐ Aphasia ☐ Dentures

PENNSYLVANIA PATIENT TRANSFER TO POST ACUTE CARE FORM

Respiratory Issues: ☐ None ☐ Oxygen Device Flow Rate ________ Smoker: ☐ Yes ☐ No

☐ CPAP ☐ BPAP ☐ Vent ☐ Other _______________________________________________________________________

|☐ Trach Type: ______________________ Size________________________ ☐ Cannula Type: ________________________ |

Diabetic: ☐ Type I ☐ Type II Glucometer ________ Date: _____________ Time: _____________

Medication given: ___________________________________________________________________________________________

Date of administration: _______________________ Time of administration: _____________________________________________

Dialysis:

Peritoneal: ☐ Yes ☐ No Dialysis Center Name: _______________________________________________________________

Hemodialysis: ☐ Yes ☐ No Shunt location: _______________________ Chair Time: ______________________________

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Pacemaker or AICD: ☐ Yes ☐ No Instructions: _______________________________ Brand Name: ____________________

☐ Baclofen Pump ☐ Insulin Pump ☐ Brain Stimulator ☐ Internal Defibrillator ☐ Zoll Life Vest ☐ LVAD ☐ Other ________

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IV Access and Location: ☐ None ☐ PICC ☐ Saline Lock ☐ IVAD/PORT ☐ AV Shunt ☐ Port ☐ Midline ☐ Other _____

Date Placed ______________ Location ___________________________________________________________________________

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Tubes and Drains: Type and Location ____________________________________________________________________________

Type and Location ____________________________________________________________________________

Type and Location ____________________________________________________________________________

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Pain: ☐ None ☐ Yes Rating (1-10) _________ Site(s) ______________________________________________________________

Pain Medication Given: (Drug, Dose, Route, Date, Time) ______________________________________________________________

Transfusions Given: ☐ Yes ☐ No Date _____________ Time________ Reason: ________________________________________

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Isolation Precautions: ☐ None ☐ Airborne ☐ Droplet ☐ Contact Site: ______________________________________________

|Isolation Reason: (if applicable) ☐ TB ☐ MRSA ☐ FLU ☐ SARS ☐ VRE ☐ ESBL ☐ C-diff Other ______________________ |

Diet: ☐ NPO ☐ Regular ☐ Diabetic ☐ Heart Failure ☐ Sodium Restrictions ☐ Renal ☐ Gluten Free ☐ Clear Liquid ☐ Full Liquid

Other ______________________________________ Tube Feeding: ☐ Yes ☐ No Type ____________ Rate _________________

Enteral Feeding: ☐ Yes ☐ No Details: ___________________________________________________________________________

Consistency: ☐ Regular ☐ Mechanical ☐ Soft ☐ Pureed Liquids: ☐ Regular ☐ Thick Liquid (Circle One: Honey, Nectar, Pudding)

Permitted Alcohol Intake: ☐ Yes ☐ No Specify: _____________________________________________________________________

Fluid Restrictions: ☐ Yes ☐ No Details: __________________________________________________________________________

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Bowel: ☐ Continent ☐ Incontinent ☐ Colostomy ☐ Other Date of last BM ______________ Comments: _____________________

Bladder: ☐ Continent ☐ Incontinent ☐ Foley Catheter ☐ S/P tube ☐ Ileostomy ☐ Urostomy Date Placed: ________________

Comments: _____________________________________________________________________________________________________

PENNSYLVANIA PATIENT TRANSFER TO POST ACUTE CARE FORM

Skin: ☐ Intact ☐ Fragile ☐ Skin Tears ☐ Surgical Site

☐ Pressure Ulcer ☐ Venous Ulcer ☐ Diabetic Ulcer ☐ Arterial Ulcer ☐ Rash ☐ Shingles

☐ Other ______________________________________________________________________________________________________

(Detail: Site, Size, Stage)

Treatment: _____________________________________________________________________________________________________

_______________________________________________________________________________________________________________

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Weight Bearing Status: ☐ R - Full weight bearing ☐ Non-weight bearing ☐ Partial with assistance ☐ Partial without assistance

☐ L - Full weight bearing ☐ Non-weight bearing ☐ Partial with assistance ☐ Partial without assistance

Mobility Function: Self Assistance Not Able Devices Used:

Walk ☐ ☐ ☐ Cane ☐

Transfer ☐ ☐ ☐ Wheelchair ☐

Toilet ☐ ☐ ☐ Walker ☐

Feed ☐ ☐ ☐ Other _______________________________________

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Special Equipment Needs: _______________________________________________________________________________________

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Personal Belongings Sent with Patient: ☐ Glasses ☐ Hearing Aid ☐ left ☐ right ☐ Dentures ☐ lower ☐ upper ☐ Partial ☐ Cane

☐ Walker ☐ Wheelchair ☐ Prosthesis ☐ Brace/Splint ☐ Other: _____________________________________________________

Immunizations/Screening: Flu Shot Date __________ Pneumonia Shot Date ______________ Tetanus Shot Date ________________

PPD: +/- Date: ____________ ☐ Negative ☐ Positive Size (mm) ______________ Other: _____________________________________

Additional information in order to meet resident’s needs: ____________________________________________________________

_____________________________________________________________________________________________________________

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Attached Documents (Current Medication Record Attached)

☐ Face Sheet ☐ POS ☐ Advance Directive ☐ HX/PE

☐ Discharge Summary ☐ Diagnostic Studies ☐ POLST ☐ Comprehensive Care Plan (include health

concerns, assessment and plan, goals,

☐ MAR ☐ Labs ☐ PT Note resident preferences)

☐ TAR ☐ Operative Report ☐ OT Note ☐

☐ Medication Reconciliation ☐ Respiratory Care ☐ ST Note ☐

Physician Orders for Ongoing Treatments ___________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Scheduled Follow-Up Appointments ____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

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Individual Completing Form: (Please print) __________________________________________________________________________

Title: ___________________________ Phone: __________________ Unit: ______________________ Date: _____________________

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Sample UPTF-PAC Form developed by:

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