Discharge Summary and Orders For Nursing Home

  • Date of Admission & Discharge
  • Principal Diagnosis
  • Secondary Diagnosis (Present On Admission)
  • Principal Discharge Diagnosis With Brief Summary (See Hospital Course Below For Details)
  • Reasons For Changed, New, Or Held Medications
  • Test Results Pending At Time Of Discharge
  • Code Status
  • Readmission Score (LACE)
  • Disposition (e.g. Skilled)
  • Procedures Or Operations
  • Transfusions
  • Complications
  • Consultants
  • Hospital Course
  • Condition On Discharge
  • Mental Status
  • Core and Reportable Measures
  • SNF ADMISSION ORDER
    • Nursing Facility Admission Diagnosis
    • Isolation
    • Treatment Preferences
    • Code Status
    • Allergies
    • Diet
    • Activity Level
    • Rehabilitation Potential
    • Therapy Consults
    • Restorative Nursing
    • Other Skilled Nursing Treatments and/or Observations
    • Respiratory: Oxygen / Bi-PAP / CPAP / Ventilator Settings
    • Skin / Wound Care
    • MEDICATIONS – Current Discharge Medication List
    • Regular Insulin Sliding Scale
    • VTE Prophylaxis Assessment
    • Follow Up Appointments
    • Patient & Family Education