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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