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Medication Review:
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Medication review performed against Discharge Record?
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Patient is taking meds as prescribed?
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If patient NOT taking meds, reason:
• • •
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Comments:
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Any labs/tests done since discharge?
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If Yes, what/where:
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If home health ordered, was patient contacted?
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Comments:
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If DME ordered, has patient received?
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Comments:
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Identified Community Resources Needed
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• • •
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Comments:
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Fall Risk Screening (if appropriate)
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Which of these assistive devices do you use?
• • •
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Comments:
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Do you have trouble with your balance?
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Have you fallen 2 or more times or had a fall with injury in the past year?
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Are you afraid of falling?
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Referrals (if appropriate)
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• • •
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Comments:
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Education reviewed and discussed by provider:
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• • •
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Advance Directives (if applicable)
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Does your family know what you want in an emergency situation if you could not speak for yourself?
• • •
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Would you like more information on advance directives?
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