Referral information

Referral source:

Referral reason:

Homebound status

 Unable to ambulate

 Unsteady gait/balance

 Requires assist of 1-2 people

 Requires assistive device

 Bed bound

 Chair bound

 Uncontrolled pain

 Difficult and taxing effort to leave home

 Unable to walk without severe weakness

 Not homebound as able to leave home without difficulty or leaves on a frequent basis

Number of steps at entry of home:

Documentation of difficult and taxing effort to leave home

Injury/illness:

Current condition:

Health status:

Patient specifics:

Caregiver information

Availability: Available. No one available. Limited.

Primary caregiver:

Cognition

Status: Alert and oriented X4. Alert and intermittent confusion. Forgetful. Disoriented.

Note:

Vital signs

B/P:

P:

R:

T:

Wgt (in lbs.):

Ht (in inches):

Fall history

Status: No falls. Frequent falls. Recent fall with injury.

Pain level

Scale (0–10):

0

Skin

Skin condition: Intact. Not intact - add site, measurement, drainage, and amount below.

Notes:

 In Use

 Compliant

 In Use

 Compliant

Bed bugs

 Currently has bed bugs.

 Has been treated for bed bugs.

 Has lived in dwelling with bed bugs.

Notes:

Review of systems

Eyes:

Ears:

Mouth:

Cardiac:

Respiratory:

Abdominal:

Urinary:

Referrals requested

 SN

 PT

 OT

 RD

 MSW

 HHA

Community resources

Resources:

Medication discrepancies

Referral source:

Discharge medications:

Medications in home:

Visit frequency

Frequency:

Patient goals

 Wound(s) healed without signs and symptoms of infection.

 Independent with medication administration.

 Stable cardiovascular and respiratory status.

 Stable blood glucose levels.

 Pain well controlled.

 Improved activity and level of endurance.

 Family able to safely provide care.

Notes:

Social concerns

Notes:

“What matters to me” - the patient

at this moment:

as a result of this support:

good day: