Athena Health Care Pre-Admission/On-Site Evaluation

Athena Health Care Pre-Admission/On-Site Evaluation 

 

Facility: 

 

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     

 

Patient Name:

Sex □ M   □ F

Birth Date:

Admission Date:

Discharge Date:

 

Patient Address:

Home Phone:

Marital Status □ S   □ M   □ D    □ W    SS#:

 

Responsible Person & Address:

Relationship

Home Phone:  Cell Phone:  Work Phone:

 

Discharge Planner:

Phone:

 

Primary Payor Source:

ID#

Secondary Payor Source

ID#

 

Prior SNF Stay  No □  Yes □   Date:

Facility:

 

Attending Physician:

Primary Care Physician:

 

Primary Diagnosis:

History of Present Illness or Injury:

 

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 

Medications	Dose	Frequency	Medications	Dose	Frequency
1			7
2			8
3			9
4			10
5			11
6			12

 

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 

 

Vital Signs:  T:_______  P:________  BP:  __________  R:  _________  POX:  _________  Height:  _________________        Weight:  _____________          Diet:  ______________  Supplements:                               Date Wt done:________          Appetite:

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: 

• Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP - Guidance to Surveyors for Long-Term Care Facilities. [Link to current CMS SOM] 

• CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines]