VULNERABLE ADULT PATIENT TRANSFER/DISCHARGE SUMMARY NURSING

Transcription

1 VULNERABLE ADULT PATIENT TRANSFER/DISCHARGE SUMMARY NURSING This form must be completed by the Discharging Nurse on the day of transfer/discharge of the patient. It should be sent/faxed to the receiving care setting within one hour of transfer and/or to the Care Coordinator, GP and District Nurse on the day of discharge. A copy should be kept in the patient s notes. Patient s name: Patient s date of birth:.. Ward/Unit: Hospital:. Consultant:. Transfer/Discharge date: Transfer/Discharge destination: Care Coordinator:.... Base:... Tel. No.:... Name and address of Next of kin/most significant other: Tel. No.:.. Date/time Next of kin/most significant other informed of transfer/discharge? Brief summary of nursing care needs (communicate essential aspects of planned care): Self-care abilities/needs: Continence needs: Mobility needs: Nutritional needs: Skin/Wound care needs: Communication needs: Memory/Orientation needs:..... Behavioural/Mood disturbance needs: Sleep/Night-time needs:... Aids/Equipment needs:..... Carer support/social needs:.... Other needs, e.g. cultural requirements:..... Tick if Supplementary Snapshot Assessment required Yes / No (Attach) Brief summary of risks and risk management strategies (attach all relevant risk assessments): Tick if Supplementary Discharge Care Plan required Yes / No (Attach) Forms faxed/sent to Care Coordinator Yes / No Date:. / Time:.. Fax No.:.. Forms faxed/sent to Receiving Care Setting (if transferred) Yes / No Date:. / Time:.. Fax No.:.. Forms faxed/sent to GP Yes / No Date:. / Time:.. Fax No.:.. Has Ambulance Crew been notified if the patient is unsafe to be left alone/requires physical handover? Yes / No Have District Nurses/Therapists and relevant others been informed of transfer/discharge (where appropriate)? Yes / No Has a Body Map been completed/attached to this form if any wounds/injuries are present (specifying cause/s)? Yes / No Print name:... Designation:.. Signature: Date/time of discharge/transfer:.../..... Date/time documents faxed/sent:..... /..

2 VULNERABLE ADULT PATIENT TRANSFER/DISCHARGE SUMMARY MEDICAL This form must be completed by the Discharging Doctor on the day of transfer/discharge of the patient. It should be sent/faxed to the receiving care setting within one hour of transfer and/or to the GP/receiving Doctor on the day of discharge. A copy should be kept in the patient s notes. Patient s name: Patient s date of birth:.. Ward/Unit: Hospital:. Consultant:. Transfer/Discharge date: Transfer/Discharge destination: GP: Surgery:..... Tel. No.:.... Date of this admission to hospital: Reasons for admission: Principal diagnosis:.... Code: Other relevant conditions/codes: Mental Health Act 1983 status: Outcomes of treatment/rehabilitation: days supply of the following drugs to take home has been dispensed (unless otherwise specified) Drugs Dose Frequency Route Course length/comments Quantity supplied Weight kg. (if under 12 yrs)..... Pharmacist s initials:... Date:... Further information, e.g. rationale for medication changes, drug sensitivities, problems with compliance/administration: Tick if Supplementary Drug Chart required Yes / No (Attach) Date/time of last medical examination:. Undertaken by:.... Declaration that the patient is medically stable and fit for transfer/discharge (sign/date):.... Note any safe discharge/vulnerability issues and how these have been addressed: Comments (e.g. follow-up treatment/rehabilitation plan, ongoing infections): Has a Do Not Attempt Cardiopulmonary Resuscitation Order Form been attached? Yes / No (If a DNAR decision has been discussed it must be attached) A detailed summary Will be sent / Will not be sent within 2 weeks from discharge An Out-Patient appointment Has been made / Has not been made Venue:. Consultant:. Date/time:... Send: White Pharmacy, Yellow - Case Notes, Pink Receiving Care Setting, Blue - Care Coordinator, Green District Nurse SNAPSHOT ASSESSMENT OF NEEDS/PLANNED CARE SUPPLEMENTARY ATTACHMENT IF REQUIRED Identified risks Risk Management Care Plan:

3 Self-care abilities/needs Rehabilitation Care Plan: Continence needs Continence Care Plan: Mobility needs Mobility Care Plan: Nutritional needs Nutritional Care Plan: Skin/Wound care needs Wound/Dressing Care Plan: Communication needs Communication Care Plan: Memory/Orientation needs Memory/Orientation Care Plan: Behavioural/Mood disturbance needs Behavioural/Mood Disturbance Care Plan: Sleep/Night-time needs Night-time Care Plan: Aids/Equipment needs Aids and Equipment Requirements: Medication needs Medication Care Plan: Other planned care:

4 DISCHARGE CARE PLAN Planned day/date/time of discharge:. Placement decision/discharge address:. Carer s capability/willingness to provide care: Community Care Plan: If capacitated: has the patient been informed of the discharge date/destination? Has the main carer been informed (if the patient consents to this, or is incapacitated)? If returning home, will the patient be: living alone living with a carer/s If returning home into the care of another, what is the extent of input: the main carer can provide? others can provide? If returning home, what does the Community Care Plan comprise?: Sign actioned/date / Add comment: Aids and equipment: Has the Care Coordinator/Manager been actively involved in discharge planning? List all necessary aids and equipment for care: Are all required aids and equipment in situ? If no, what is/are outstanding? Plan for after-care/follow-up: Which professionals/care staff will be involved post-discharge? What Out-patient Clinic, follow-up appointments are arranged? Plan for day of discharge: What transport is required/arranged? Is an escort required?: DISCHARGE CHECKLIST Placement: Own/family home Gen Residential Gen Nursing EMI Residential EMI Nursing Patient assessed as meeting: Nil funding criteria Funded Nursing Care NHS Continuing Care Care Package: Self-funded Means-tested Funded (Approved by Panel) Patient: Identified as DTOC t identified as DTOC Safe discharge: Safe Discharge Planning Case Conference required SDP Case Conference held SUPPLEMENTARY DRUG CHART

5 7 days supply of the following drugs to take home has been dispensed (unless otherwise specified) Drugs Dose Frequency Route Course length/comments Quantity supplied Weight kg. (if under 12 yrs)... Pharmacist s initials:.... Date:... Further information, e.g. rationale for medication changes, drug sensitivities, problems with compliance/administration: Send: White Pharmacy, Yellow - Case Notes, Pink Receiving Care Setting, Blue - Care Coordinator, Green District Nurse