MEDICAL CERTIFICATION FOR MEDICAID LONG-TERM CARE SERVICES AND PATIENT TRANSFER FORM
Patient Name:
DOB:
A. PATIENT INFORMATION
I. TRANSFERRED FROM
Gender:
Facility Name:
Male
Female
Hispanic Ethnicity:
Yes
No
Date:
Unit:
Race:
White
Black
Other:
Phone:
Fax:
Language:
English
Other:
Discharge
B. SIGHT
HEARING
Nurse:
Phone:
Impaired
Normal
Impaired
Discharge Date:
Normal
Admit Date:
Hearing Aid
Discharge Time:
Blind
Deaf
Admit Time:
L
R
J. TRANSFERRED TO
C. DECISION MAKING CAPACITY (PATIENT):
Facility Name:
Capable to make healthcare decisions
Requires a surrogate
Address 1:
D. EMERGENCY CONTACT
Address 2:
Name:
Name:
Fax:
Phone:
Phone:
Phone:
K. PHYSICIAN CONTACTS
E. MEDICAL CONDITION / RECENT HOSPITAL STAY
Primary Care Name:
Primary Dx at discharge:
Phone:
Reason for transfer (Brief Summary):
Hospitalist Name:
Phone:
Surgical procedures performed during stay:
None
L. TIME SENSITIVE CONDITION SPECIFIC INFORMATION
Medication due near time of transfer / list last time administered
Other diagnoses:
Script sent for controlled substances (attached):
Yes
No
Anticoagulants
Date:
Time:
F. INFECTION CONTROL ISSUES
Antibiotics
Date:
Time:
PPD Status:
Positive
Negative
Not known
Insulin
Date:
Time:
Screening date:
Associated Infections/resistant organisms:
Other:
Date:
Time:
Has CHF diagnosis:
MRSA
Site:
Yes
No
VRE
Site:
If yes; new/worsened CHF present on admission?
ESBL
Site:
Yes
No
MIDRO
Site:
Last echocardiogram: Date:
LVEF
%
C-Diff
Site:
On a proton pump inhibitor?
Yes
No
Other:
Site:
If yes, was it for:
In-hospital prophylaxis and can be
Isolation Precautions:
None
discontinued
Contact
Droplet
Airborne
Specific diagnosis:
G. PATIENT RISK ALERTS
On one or more antibiotics?
Yes
No
None Known
Harm to self
Difficulty swallowing
If yes, specify reason(s):
Elopement
Harm to others
Seizures
Pressure Ulcers
Falls
Other:
Any critical lab or diagnostic test pending
at the time of discharge?
Yes
No
RESTRAINTS:
Yes
No
If yes, please list:
Types:
Reasons for use:
M. PAIN ASSESSMENT:
Pain Level (between 0 - 10):
ALLERGIES:
None Known
Yes, List below:
Last administered: Date:
Time:
N. FOLLOWING REPORTS ATTACHED
Latex Allergy:
Yes
No
Dye Allergy/Reaction:
Yes
No
Physicians Orders
Treatment Orders
H. ADVANCE CARE PLANNING
Discharge Summary
Includes Wound Care
Please ATTACH any relevant documentation:
Medication Reconciliation
Lab reports
Advance Directive
Yes
No
EKG
Discharge Medication List
X-ray
MRI
PASRR Forms
CT Scan
Living Will
Yes
No
Social and Behavioral History
DO NOT Resuscitate (DNR)
Yes
No
DO NOT Intubate
Yes
No
ALL MEDICATIONS: (MAY ATTACH LIST)
DO NOT Hospitalize
Yes
No
No Artificial Feeding
Yes
No
Hospice
Yes
No
AHCA 5000-3008, ________________ (incorporated by reference in Rule 59G-1.045, F.A.C.)
revised October 2015
1
2
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