FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT

NAME OF FACILITY ADDRESSFACILITY LOCATION PROC
COMPANY LOG NAME OF FACILITY ADDRESS OF FACILITY
CONTRACT OPERATOR FACILITY LIST OHIO ENVIRONMENTAL PROTECTION

FACILITY EMPLOYEE [CCR TITLE 23 SECTION 2715(F)]
(FACILITY NAME) EMERGENCY OPERATIONS PLAN ANNEX C EVACUATION ATTACHMENT
(FACILITY NAME) EMERGENCY OPERATIONS PLAN ANNEX E SHELTER IN

Discharge Summary: General Format

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT

Facility Discharge Summary

Original to be given to resident and copy to be kept as part of medical record to document follow up


RFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT esident Name: Date of Birth:

AFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT dmission Date: Discharge Date:

AFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT ttending Physician:


PFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT rimary Diagnosis:

SFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT econdary Diagnoses:

Brief Summary of Resident’s Stay:

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT


LFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT aboratory / Diagnostic Results: (Please list only the most pertinent results received during the resident’s stay)

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT


CFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT onsultation Reports:

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT

Discharge Medications: (Identify medications that are different from initial admission orders)

Medication

Route

Dosage

Frequency

Notes






















NFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT ursing Discharge Instructions (including Medication Reconciliation)


FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT

Dietary (including any special instructions)

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT


Social Services

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT


RFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT estorative Therapy (PT/OT/ST)

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT

Follow up Appointments in the Community

Date of Appointment

Type of Consultation / Physician







Post Discharge Plan of Care: (Include resident’s current status upon discharge, medical and non- medical devices to be used, Home Care Services and any measures in place to assist resident in readjusting to community life, etc.)

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT


FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT

HFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT ome Care Organization Phone Number:


Resident/Resident Representative Education: (i.e. Diabetic management, Wound care, Ostomy care, etc.)

Type of Education Provided

Return Demonstration (if applicable)

Additional Comments








RFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT esident/Resident Representative Signature:

CFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT omments:

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT

AFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT ttending Physician:

CFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT harge Nurse:

DFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT ietitian:

SFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT ocial Services:

RFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT ehab:

Resident Name:

PFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT rimary Care Physician in Community: Tel. #:


Within 7 days of discharge member(s) of the IDT (to be designated as per facility protocol) is responsible for calling the resident to ensure successful re-acclimation to the community.

It is recommended that the caller review the resident’s:


  1. Current Health Status

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT





  1. Medications (compliance, any difficulty obtaining medications, etc.)

*If an issue is identified, a designated clinician (i.e. Nurse Manager) should conduct an additional follow up


FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT




  1. Appointments

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT




  1. Homecare Agency & Services (if applicable)

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT




  1. Concerns / Plan for what to do if a problem arises.

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT




Additional comments:

FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT FACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT





DFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT ate:

CFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT aller name:

SFACILITY DISCHARGE SUMMARY ORIGINAL TO BE GIVEN TO RESIDENT ignature:


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(NAME OF FACILITY) C HILD CARE EMERGENCY BASIC EMERGENCY
(NAME OF FACILITY) C HILD CARE EMERGENCY CHECKLISTS DATE
0510 SECTION 22 12 16 FACILITY ELEVATED POTABLEWATER STORAGE


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