| PATIENT NAME: _________________________ | DISCHARGE DATE: _________________________ | SOC DATE: _________________________ |
| HOME HEALTH AGENCY: _________________________ HH CASE MANAGER CONTACT # (if different): _________________________ |
SOC RN CONTACT #: _________________________ TELEMONITORING AVAILABLE?: _____ Yes _____ No |
The PERFECT Form is a communication and accountability tool developed to encourage collaboration after hospital discharge between home health partners and the clinical team at RUSH. The information provided by the admitting RN in the field provides a critical snapshot of the patient in their home environment and helps us define care expectations for a successful transition from hospital to home.
How to use the PERFECT form:
- Please check yes or no for each of the care expectations listed
- Utilize the interventions column as a guide for addressing problem areas
- Use the comments section to provide any additional information
- Actions taken to resolve a problem
- Additional information about a situation
- Please contact Madeleine Rooney, MSW at RUSH at 312-942-6995 within 48 hrs. if any issues remain resolved or if any delay in care is present
- Fax completed form to 312-563-6548 within 72 hrs. of admission to the agency
- Attach additional comments on separate pages as neede
Hand off communication is essential to assure quality coordination of care.
| Care Expectations | Interventions | Additional Information | ||
|---|---|---|---|---|
| Plan of Care | ___ Yes ___ No |
Plan of care discussed with pt. & family/ consent for care signed? |
|
Note any special orders: |
| ___ Yes ___ No |
Health literacy issues identified at SOC? | |||
| ___ Yes ___ No |
Barriers to scheduling visits present? | |||
| Equipment/ Supplies | ___ Yes ___ No |
Provided within expected timeframe? |
|
DME Provider #: |
| ___ Yes ___ No |
Additional DME needs? | |||
| ___ Yes ___ No |
Telemonitoring needed? | |||
| Reconciliation of Medications | ___ Yes ___ No |
Pt has dc instructions? |
|
Pharmacy #: |
| ___ Yes ___ No |
D/C list match meds found in home? | |||
| ___ Yes ___ No |
RN contacts patient w/in 24 hrs-missing meds obtained | |||
| ___ Yes ___ No |
Pt. able to obtain meds w/out barriers? | Who fills the pillbox? | ||
| ___ Yes ___ No |
Pillbox in home? | |||
| ___ Yes ___ No |
Are medications adequately managed? | |||
| Follow Up MD | ___ Yes ___ No |
MD appt scheduled within 10 days? |
|
PCP #:
MD Appt: MD Appt: MD Appt: |
| ___ Yes ___ No |
Can pt physically get to the appt? | |||
| ___ Yes ___ No |
Is transportation available for f-up appt.? | |||
| Expectations | ___ Yes ___ No |
Is patient satisfied with discharge plan and services provided? | 48 hour quality assurance call completed | |
| Caregiver & Support | ___ Yes ___ No |
Is primary caregiver available? |
|
Caregiver: |
| ___ Yes ___ No |
Community resources needed? | Pt Support: | ||
| ___ Yes ___ No |
Were community resources arranged prior to d/c? | Contact #: | ||
| Therapy | ___ PT ___ OT ___ ST ___ None |
Therapies provided w/in 72 hrs unless otherwise ordered? | Contact MD if additoinal orders needed |
| Was RN visit performed 24 hrs post D/C? ___ Yes ___ No | ||
|---|---|---|
| ___ Patient/family declines care | ___ Unsafe environment | ___ Family refuses out of network co-pay |
| ___ Care exceeds capacity | ___ No skilled need | ___ Patient re-hsopitalized before first visit |
| ___ Unable to local patient | ___ Patient not discharged from hospital | ___ Insurance out of network |
| ___ Cancelled by referral source | ___ Another agency providing services | ___ Referred to another agency |
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