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AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits

Electronic Reports

Table 4. Sample ED Treat and Release Report

Facility Name:
Month:

Average Daily Census 30 Total Transfers (Obs, ED) 11
Resident Days (including bed holds) 300 Total Residents (Obs, ED) 10

 

  ED Visit
Resident ED Visit Date ED Discharge Diagnosis
Resident A 11/11/2013 Angina
Resident B 11/20/2013 UTI
Resident C 11/15/2013 Anemia
Resident D 11/13/2013 COPD
Resident G 11/2/2013 Gastroenteritis
Resident G 11/11/2013 Fracture
Resident J 11/20/2013 G tube replacement
Resident P 11/10/2013 Dehydration
Resident R 11/1/2013 Pneumonia
Resident T 11/30/2013 Asthma
Resident Y 11/30/2013 Laceration
Total reasons   21
% Total reasons    

Table 4 (continued)

  Reason for Transfer
Resident Cardiac/
Circulatory
Symptoms		 Respiratory
Symptoms		 Mental/
Psychiatric/
Neurological
Symptoms		 Gastrointestinal/
Genitourinary
Symptoms		 Endocrine/
Metabolic/
Nutrition
Issues		 Wound or
Skin Issues
Resident A X          
Resident B     X      
Resident C            
Resident D   X        
Resident G       X X  
Resident G            
Resident J       X    
Resident P       X X  
Resident R   X        
Resident T   X        
Resident Y            
Total reasons 1 3 1 3 2 0
% Total reasons 5 14 5 14 10 0

Table 4 (continued)

  Reason for Transfer
Resident Injury: Fall Related Injury: Not Fall Related Musculoskeletal Symptoms Abnormal Labs or Anemia Fever/Possible Infection Malaise/Fatigue Possible Surgical Complication
Resident A              
Resident B              
Resident C       X   X  
Resident D         X    
Resident G       X      
Resident G X            
Resident J              
Resident P       X   X  
Resident R       X X    
Resident T         X    
Resident Y   X          
Total reasons 1 1 0 4 3 2 0
% Total reasons 5 5 0 19 14 10 0

Table 4 (continued)

  Reason for Transfer: Treatment Unavailable at Facility Authorized by:
Resident Diagnostics: Radiology, Imaging IV Access: PICC, Central, Periph; Meds or Fluids Transfusion Catheter Insertion/
Reinsertion		 Primary Care Physician Covering Provider Medical Director Medicare Managed Care Organization Outside Clinic or Service
Resident A         X        
Resident B         X        
Resident C     X     X      
Resident D             X    
Resident G           X      
Resident G           X      
Resident J       X   X      
Resident P         X        
Resident R   X     X        
Resident T               X  
Resident Y         X        
Total reasons                  
% Total reasons                  

Table 4 (continued)

  Nursing Home Treatments 24 Hours Prior to Transfer
Resident Labwork Obtained X Rays Obtained IV Fluids/
Subcutaneous Fluids		 Oxygen Respiratory Treatment Respiratory Suctioning Medications: IV, Intramuscular, or SQ Medications: Oral
Resident A       X       X
Resident B               X
Resident C X              
Resident D       X X      
Resident G X     X        
Resident G                
Resident J                
Resident P X X            
Resident R X X   X X     X
Resident T       X X      
Resident Y                
Total reasons                
% Total reasons                

Table 4 (continued)

  Seen by (Within 24 Hours Prior to Transfer): Prior ED Visit Prior Hospital Discharge
Resident Primary Care Physician Covering Provider Consulting Physician Nurse Practitioner or Physician's Assistant Respiratory Therapist Other 0-3 Days 4-30 Days 0-7 Days 8-30 Days
Resident A X                  
Resident B       X         1  
Resident C       X           1
Resident D               1    
Resident G X                  
Resident G               1    
Resident J               1    
Resident P       X       3   1
Resident R       X            
Resident T X           1     1
Resident Y                    
Total reasons                    
% Total reasons                    
Page last reviewed September 2017
Page originally created September 2017

Internet Citation: AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits. Content last reviewed September 2017. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/treat-release.html

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