Re-Engineered Discharge (RED) Toolkit

Tool 3 Continued

RED Discharge Preparation Workbook

This workbook available for download in two formats:


Patient Name _________________________   MRN ________________   DOB ______________

Room # ______________

Date of admission ______________

  Language preference Interpreter/Translation
Needed (Y/N)
Spoken communication    
Written materials    
Phone communication    

Fill out Contact Sheet for patient, proxy, and caregiver contact information.

MEDICAL TEAM ______

Attending: ________________________________
Pager # __________________________________

_________________________________________
Pager # ___________________________________

_________________________________________
Pager # ___________________________________

Case Manager: ___________________________
Pager # _________________________________

Language Services: _______________________
Pager # _________________________________

Family worker: ____________________________
Pager # _________________________________

Pages to Team:

Pager: _____ Time: _____ C/B?: Y N Pager: _____ Time: _____ C/B?: Y N Pager: _____ Time: _____ C/B?: Y N
Pager: _____ Time: _____ C/B?: Y N Pager: _____ Time: _____ C/B?: Y N Pager: _____ Time: _____ C/B?: Y N
Pager: _____ Time: _____ C/B?: Y N Pager: _____ Time: _____ C/B?: Y N Pager: _____ Time: _____ C/B?: Y N
Pager: _____ Time: _____ C/B?: Y N Pager: _____ Time: _____ C/B?: Y N Pager: _____ Time: _____ C/B?: Y N

DE Time: (Record time spent on patient's case)

Date: ______ DE: ____ Total: ______ Date: ______ DE: ____ Total: ______ Date: ______ DE: ____ Total: ______
Date: ______ DE: ____ Total: ______ Date: ______ DE: ____ Total: ______ Date: ______ DE: ____ Total: ______
Date: ______ DE: ____ Total: ______ Date: ______ DE: ____ Total: ______ Date: ______ DE: ____ Total: ______

Floor Nurse: (Name of patient's nurse)

Date: _______ Nurse: __________   Date: _______ Nurse: __________   Date: _______ Nurse: __________  
Date: _______ Nurse: __________   Date: _______ Nurse: __________   Date: _______ Nurse: __________  
Date: _______ Nurse: __________   Date: _______ Nurse: __________   Date: _______ Nurse: __________  

Contacts with family/caregiver

Date: _______ Name: __________   Date: _______ Name: _________   Date: _______ Name: __________

Date Outstanding Patient Teaching/Information Date Addressed
     
     
     
     
     
     

1. Diagnoses

Admitting Dx: ____________________________________________________________________________

Comorbidities: ___________________________________________________________________________

Discharge Dxs ___________________________________________________________________________

2. Followup Appointments

PCP Appointment

____ Patient has PCP? If NO, Preferences (gender, location)? ___________________________________

Patient requests for PCP appt (weekdays, time of day): ________________________________________

PCP Name Day / Date / Time
   
Clinician to see at appt
(if not PCP)
Location
  Address/Floor:
Phone #:
Fax #:

Does patient have transportation to PCP appt?

____ Yes ___ No ____ Transportation options discussed:

Team appt. requests: _____________________________________________________________________

Additional Appointments, Tests, or Lab Work to be done POSTDISCHARGE

****Attach Additional Appointment Sheet if Needed****

Day / Date / Time Phone and Fax # Reason / Test / Lab
  Ph:
Fax:
 
Provider Location (Address, floor)
   
How patient will get to appointment
 

 

Day / Date / Time Phone and Fax # Reason / Test / Lab
  Ph:
Fax:
 
Provider Location (Address, floor)
   
How patient will get to appointment
 

 

 

Day / Date / Time Phone and Fax # Reason / Test / Lab
  Ph:
Fax:
 
Provider Location (Address, floor)
   
How patient will get to appointment
 

 

 

Day / Date / Time Phone and Fax # Reason / Test / Lab
  Ph:
Fax:
 
Provider Location (Address, floor)
   
How patient will get to appointment
 

 

 

Day / Date / Time Phone and Fax # Reason / Test / Lab
  Ph:
Fax:
 
Provider Location (Address, floor)
   
How patient will get to appointment
 

 

 

Day / Date / Time Phone and Fax # Reason / Test / Lab
  Ph:
Fax:
 
Provider Location (Address, floor)
   
How patient will get to appointment
 

 

3. Medicine

Allergies ____    No known allergies ____

Allergy Patient Confirm
(Y/N)
If No, Explain Allergy Patient Confirm
(Y/N)
If No, Explain
           

4. Pharmacy

Uses hospital pharmacy? No ____ Yes ____

Labs/Tests Pending Community Pharmacy Name Phone #, Street Address, City
   

Pt. plan to pick up meds upon d/c: ______________________________________________________

Pt. requests pill box? No ____ Yes ____ (Pill box given ____)

5. Diet

Discharge diet   Pt. needs diet info. _____________________________

6. Substance use

Substance SCM Patient Report Current Tx. or Interested in Cessation Info?
Alcohol      
Tobacco      

7. Durable medical equipment needed at home?

No ____ Yes ____

If pt. checks blood sugar with glucometer, how many times daily? _______

New durable medical equipment ordered: Yes ____ No ____

Type ____________________________________________________________________________________

Company name: __________________  Contact: _______________________________________________

Address: __________________________ Phone: _______________________________________________

Delivery date: ____________________________________________________________________________

Type ____________________________________________________________________________________

Company name: __________________  Contact: _______________________________________________

Address: __________________________ Phone: _______________________________________________

Delivery date: ____________________________________________________________________________

8. Current or New Outpatient Services (ex. VNA, PT)? _______________________________

Service __________________________________________________________________________________

Company name: __________________  Contact: _______________________________________________

Address: __________________________ Phone: _______________________________________________

Date scheduled: __________________________________________________________________________

Service __________________________________________________________________________________

Company name: __________________  Contact: _______________________________________________

Address: __________________________ Phone: _______________________________________________

Date scheduled: __________________________________________________________________________

Service __________________________________________________________________________________

Company name: __________________  Contact: _______________________________________________

Address: __________________________ Phone: _______________________________________________

Date scheduled: __________________________________________________________________________

9. Outstanding Tests/Labs

Labs/Tests Pending Date Conducted Results Expected Who Will Follow Up on the Result
       
       

Final teaching completed? Yes ____ Done by: DE ____ Other ________________ No ____

Reviewed what to do about problems? Yes ____ No ____

Patient understanding confirmed? Yes ____ No ____

Medicines reconciled with patient and medical team prior to final teaching? Yes ____ No ____

National guidelines checked prior to final teaching? Yes ____ Date: _________ No ____

AHCP given and reviewed by DE with patient?

Yes ____ Time spent: ____minutes DE____

No ____ Date mailed: _________

If mailed, was patient called by DE to review AHCP? Yes ____ Date: __________ DE ____ No ____

Communication/Notes

 
Page last reviewed March 2013
Internet Citation: Tool 3 Continued. March 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/red/toolkit/dischargeprep.html