Athena Health Care Pre-Admission/On-Site Evaluation
Athena Health Care Pre-Admission/On-Site Evaluation
Facility:
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Clinical Evaluator: |
Hospital Location/Date of Eval:
Unit Phone Number: |
Patient Accepted □ Denied □ □ Complex Patients LOC discussed with DNS |
Anticipated Length of Stay: □ STR □ LTC □ HOSPICE □ RESPITE
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Patient Name: |
Sex □ M □ F |
Birth Date: |
Admission Date: |
Discharge Date:
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Patient Address:
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Home Phone: |
Marital Status □ S □ M □ D □ W
SS#: |
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Responsible Person & Address: |
Relationship |
Home Phone: Cell Phone: Work Phone: |
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Discharge Planner: |
Phone: |
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Primary Payor Source: |
ID# |
Secondary Payor Source |
ID#
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Prior SNF Stay No □ Yes □ Date: |
Facility: |
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Attending Physician: |
Primary Care Physician:
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Primary Diagnosis: |
History of Present Illness or Injury:
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Allergies: Smoker: Yes□ No □ Quit □ When:
Etoh: Yes □ No □ Drug Use Yes □ No □
CIWA Yes □ No □
Surgeries During this Hospitalization:
Past Medical History:
□ HTN □ CHF □ CVA □ ESRD □ PVD □ GERD □ AFIB □ Cad/Angina □ UTI □ MI
□ COPD □ Diabetes □ Pneumonia □ Anemia □ Aphasia □ Hyperlipidemia □ Dementia
□ Depression □ Anxiety Disorder □ Chemical Dependency □ Psychiatric Disorder □ MR/DD
□AICD □ Pacemaker
FLU VACCINE: No □ Yes □ Date Given:
PNEUMO VACCINE: No □ Yes □ Date Given:
TB SCREEN: No □ Yes □
MEDICARE D PLAN: ID#:
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Diagnostic Procedures and Results:
Date of CXR Results:
Pertinent and/or Abnormal Lab Values:
MAR ENCLOSED: □ Yes □ No
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Medications |
Dose |
Frequency |
Medications |
Dose |
Frequency |
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1 |
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7 |
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2 |
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8 |
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3 |
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9 |
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4 |
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10 |
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5 |
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11 |
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6 |
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12 |
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IV Solution: Route/Date of Insertion:
□ PICC - □ Valved □ Non-valved □ Peripheral
Date Last Received:__________ □ Implantable Port □ Heplock □ Other
□ TPN □ PPN Blood Transfusion Date(s):____________________
Infection: □ No □ Yes Culture: □ No □ Yes Results:
Site(s):
IV Antibiotics: □ Yes □ No Last Dose of IV Antibiotic: _________________________
IV Medications: □ Yes □ No Last Dose of IV Medication: _________________________
Isolation: □ No □ Yes □ VRE □ MRSA □ CDIFF
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Vital Signs: T:_______ P:________ BP: __________ R: _________ POX: _________ Height: _________________ Weight: _____________ Diet: ______________ Supplements: Date Wt done:________ Appetite: |
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02 at ________ Liters via: □ Nasal Cannula □ Mask □ Nebulizer □ CPAP □ BIPAP □ Other Frequency: □ PRN □ Continuous □ Ventilator Lung Sounds: □ Trach Type/Size: □ Suctioning: Frequency:____________ |
EXTENSIVE/OTHER SERVICES
□ Chemotherapy □ Fluid Intake & Output □ Transfusion: Blood/Blood Products
□ Epidural, PCA pump, □ Ostomy Care □ Suctioning: Nasopharyngeal baclofen pump
□ Oxygen Therapy (continuous) □ IV medications/ med additives □ Dialysis □ Radiation Therapy
□Continued Chemotherapy : When_________________ Where, if known _____________________
□Continued Radiation Therapy: When ______________ Where, if known _____________________
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Cognitive Status: □ Alert □ Oriented x 1 2 3 □ Impaired Memory □ Lethargic □ Unresponsive □ Follows Simple Commands □ Cannot Voice Needs □ Confused □ Restraint: Type:_______D/C date____ |
Psychological/Social Behavior Status □ Agitated □ Uncooperative □ Wanders/elopement risk □ Verbally disruptive □ Physically aggressive □ Sexually aggressive □ Psychiatric Evaluation: Date: __________________ Enclosed □ Yes □ No |
Vision □ Good □ Impaired □ Blind □ Glasses □ Cataracts
□ Dentures |
Hearing □ Good □ Impaired □ Deaf R/L □ Hearing Aid |
Speech:
□ Clear □ Slurred □ Aphasic □ Dysphagia □ Aspiration Precautions
□ Swallow Evaluation Date: ____________________________ Outcome: ___________________
__________________________________________________________________________________
__________________________________________________________________________________
□ Language Barrier Language Spoken: ________________________________________
PT/OT (Functional Ability): Weight Bearing Status:__________
Bathing: □ Independent □ Assist of 1 □ Assist of 2 □ Total
Dressing: □ Independent □ Assist of 1 □ Assist of 2 □ Total
Eating: □ Independent □ Assist □ Total feed □ Tube Type: □ G □ J □ G to J
□ Formula ____________________________________
Urinary: □ Independent □ Assist of 1 □ Assist of 2 □ Foley □ Continent □ Incontinent
Bowel: □ Continent □ Incontinent □ Ostomy Type:_________________ LBM___________
Transferring: □ Independent □ Assist of 1 □ Assist of 2 □ Hoyer
Ambulation/Distance/Devices Used: □ Independent □ Assist of 1 □ Walker □ Cane □ Wheelchair
Skin Integrity: □ Intact □ Reddened □ Edematous
Wound Location: ______________________ Stage: _________ Size: ________
Treatment: ______________________________________________________________
Special Needs/Equipment/Mattress/Bed: _______________________________________
Rashes/other skin problems:_________________________________________________
Equipment/Treatments/Other Needs:
□ Trapeze □ CPM □ Slide Board □ Prosthesis □ Calorie Count □ I&O □ Daily Weights □ Dressing Supplies □ Suction □ IV Supplies □ Cast □ Crutches □ Cane □ Wheelchair
□ Bariatrics
Dialysis □ Hemo □ PD □ AVF □ Catheter Access site:_______________
Where:_____________________ When:_____________Who transports:____________________
Current Living Situation:_____________________________________________________________
Services in the Home Prior to Hospitalization: ____________________________________________
Barriers to Discharge: _____________________________________________________________
Code Status: _______________ Advance Directive:_______________ Organ Donor: □ Yes □ No
References:
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Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP - Guidance to Surveyors for Long-Term Care Facilities. [Link to current CMS SOM]
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CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines]
