Boston Health Care for the Homeless Program



McInnis House Clinic

Medical Respite Data Form

D

Name: _____________________________ DOB_______/______/_____ Admit date: ________/________/_______

Case Management Psychosocial Assessment:

Housing:

Length of this episode of homelessness: _______

Date first became homeless ____/___/_____

Where does patient stay? _____________________________________________________

Has housing application been filed? [pic] Yes, [pic] No

If yes, where? _______________________________________________________

Contact name: _______________________________________________________

telephone #:_____________________________

Where does patient want to go upon discharge? ___________________________________

_________________________________________________________________________

Family

When was last family contact? ___________ With whom? ____________

Does patient have children? [pic] Yes, [pic] No

If yes, what are the ages of the children: _________________________________

Legal

History of legal problems? [pic] Yes, [pic] No Probation Officer? [pic] Yes, [pic] No

Ending court data _________________ Name: ____________________

Telephone: ________________

Education

What is patient’s highest grade completed? _______________

Is patient interested in further education or training? [pic] Yes, [pic] No

Employment

Is patient working? [pic] Yes, [pic] No When did patient last work?______________

What type of employment? _________________________________________

Veteran

Is patient a veteran? [pic] Yes, [pic] No

Is patient receiving veteran’s services? [pic] Yes, [pic] No

Type of discharge? __________________________________

Substance Abuse Hx

Does patient have history of substance abuse? [pic] Yes, [pic] No

Is the patient interested in treatment program? [pic] Yes, [pic] No

Signature/date/time

Discharge Date:________________ Type of Discharge:

[pic] Scheduled

Discharge disposition:_______________________ [pic] Unscheduled administrative

[pic] Unscheduled AMA

Discharge diagnosis:_________________________ [pic] Unscheduled AWOL

Signature/date/time

Name: _____________________________ DOB_______/______/_____ Admit date: ____/________/_______

Time:

Initial Nursing Assessment:

Temp: _____ BP:_____ Pulse:_____ Resp:_____ Height:_____ Weight:_____

Allergies/type of reaction:____________________________________________________

Reason for admission/Chief complaint:_________________________________________

Past medical history (liver dz, cardiac, COPD, DM, surgical hx)_________________________

_______________________________________________________________________________

Medications: __________________________________________________________________

|Substance of abuse |Route (smoke, inject, |Last use (kind |Medical (DTs, SZ) |Hx of treatment |

| |drink…) |Quantity) | |(detox, programs) |

|EtOH | | | | |

|Heroin | | | | |

|Cocaine | | | | |

|Benzos/other | | | | |

Assessment:

System (Circle problem) Complaint (describe)

General: weight loss/gain

mobility, hygiene, fever, fatigue

mental status, coherent speech

sleep disturbance, other

HEENT: visible head trauma

visual/eye problem

hearing/ear problem

dental problem, dentures

Pain: Location

Quality

Duration

Severity (1-10)

What makes it better or worse?

Skin integrity: bruises

open wounds, ulcers

rashes, dressings

Bowel Bladder

Constipation Frequency

Diarrhea Urgency

Incontinence Painful

Bleeding Incontinence

Other

Gyn Hx: pregnancies

LMP

Any Gyn problems?

Name: _____________________________ DOB_______/______/_____ Admit date: ____/________/_______

Abdomen/eating: Appetite prob

Nausea/vomiting, Abdominal pain

Trouble swallowing or chewing

Special diet

Cardiac/Chest: breast problem

SOB palpitations

fainting orthopnea

other chest pain

Pulmonary: cough/sputum

SOB, hemoptysis DOE

crackles, wheezes, other

Extremities: edema, frostbite

claudication, cyanosis

other foot problems

Musculoskeletal: back pain,

fracture, contractures, arthritis

other

Neurologic: seizure, weakness

pain, tingling or numbness,

dizziness, headache, other

Emotional/Psychiatric:

Sad, anxious, fearful, angry

recent losses, poor self esteem,

hopeless, hallucinations, other

Abuse Hx: hx of violence,

Has anyone ever hurt you? Are you

concerned about your safety?

Name:_____________________ DOB:____/_____/_____ Admit ____/_____/_____

10/20/2004

-----------------------

EMR # ______________ SS# _____-_____-______ DOB __/___/____ AGE ____________

Last Name: _____________________ First Name: ______________________

Alias: __________________________ Marital status: __________ Gender: M [pic] , F [pic]

Mailing Address: ________________________________________________________________

Admission date ____/____/____ Ethnicity [pic] White, not Hispanic

[pic] Black, born in US

Referring hospital #______________ [pic] Black, not born in US

[pic] Hispanic

U.S. Citizen: Yes [pic]. No [pic] [pic] Native American [pic] Pacific Islander

[pic] Asian [pic] Native Hawaiian

Emergency contact: [pic] Other

Name:______________________________ Relation to patient:_________________________

Address:__________________________________ Telephone #:______________________

Reason for referral: _______________________________________________________________

Did BHCHP staff make referral? [pic] Yes, [pic] No

Site from which referral was made:

[pic] BMC/inpatient [pic] BMC/ER [pic] BMC/BHCHP [pic] BMC/Specialty [pic] BMC/day surg.

[pic] MGH/inpatient [pic] MGH/ER [pic] MGH/BHCHP [pic] MGH/Specialty [pic] MGH/day surg.

[pic] LSH/inpatient [pic] LSH/ER [pic] LSH/BHCHP [pic] LSH/Specialty

[pic] Other Hosp/inpt [pic] Other Hosp/ER [pic] OtherHosp/clinic [pic] OtherHosp/day surgery

Name of other hospital: _____________________________________________________

[pic] Shelter _________ [pic] Detox [pic] Transitional Program ____________________

[pic] Street Outreach/van [pic] Street Outreach/daytime, [pic] Street Outreach/Night Center

[pic] SFH [pic] Nursing Home:__________________ [pic] Racetrack

[pic] Other, _________________________________________________

Health Insurance RID # _____________________________

|Name |Coverage |Type |Comments |Date |Date Ineligible |Policy # |Mass Health # |

| | | | |Eligible | | | |

|MassHealth |[pic] Basic | | | | | | |

| |[pic] Standard | | | | | | |

|Medicaid Pending | | | | | | | |

|Medicare | | | | | | | |

|Private Ins | | | | | | | |

|City VA | | | | | | | |

|F/C BHCHP | | | | | | | |

|F/C BHCHP Pending | | | | | | | |

Benefits

|Name |Amount received |App. Submitted? |Start date |End Date |

|SSI | | | | |

|SSDI | | | | |

|EAEDC/TAFDC | | | | |

|Veterans | | | | |

Clinicians

Page 3

Supports (friends, religion, family, therapist)______________________________________

What feels stressful in patients life?______________________________________________

Relaxation techniques:_______________________________________________________

Sexual pattern, problems, protection? ___________________________________________

Patient goals for this admission:________________________________________________

_________________________________________________________________________

Nursing goals for this admission: ______________________________________________

_________________________________________________________________________

Signature/date/time

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