Interagency Nursing Communication Record Form
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1Patient name:
Form – B
Date of birth:
INTERAGENCY NURSING COMMUNICATION RECORD
Social Security #:
Purpose: To provide pertinent information for patients being discharged or
transferred throughout the health care continuum.
Instructions: To be sent to the receiving facility upon discharge.
Discharge to:
home health agency
long term care
rehabilitation
outpatient services
other:___________
Admit from:
nursing home:_______________________
assisted living
other:________________________
Allergies/Reactions (include medications, food, latex environmental etc.):
No known allergies
______________________________________________________________________________________________
______________________________________________________________________________________________
Height: _______
cm
inches
Weight:
______
kg.
lb.
Diabetes:
yes
no
Pulse: ________
Temperature: _______
Respiration rate: _________ Blood pressure: ______________
Adult assuming care:
N/A Name: _______________________________________
Relationship:
Phone #: (______)________________
adequate
poor
blind
no
yes
with patient
Vision:
Glasses/Contacts:
Hearing:
adequate
poor
deaf
Hearing aid:
right
left
with patient
Dentures:
full
upper
lower
partial
with patient
Mental status:
alert
confused
unresponsive Oriented:
person
place
time
Behavior:
cooperative
uncooperative
wandering
noisy
aggressive
Communication:
speaks
writes
gestures
Understanding:
speaks
writes
gestures
Language:
English
other: _______________
needs interpreter
walker
wheelchair
cane
other: __________________
Mobility aids:
History of falls:
yes
no
Fall risk:
yes
no
ACTIVITIES OF DAILY LIVING (mark as appropriate)
Activities
Total Assist Partial Assist Self Care
Activities
Total Assist
Partial Assist
Self Care
Bathing
Bowel
Dressing
Bladder
Eating
Bowel incontinence:
yes
no
Turning
Date of last bowel movement: ____________
Transfers
Bladder incontinence:
yes
no Last urine void: _________
Ambulating
Date Foley inserted/changed: _____________ time: ________
Diet:______________________________________ If Foley discontinued, date: _______________
Type of infusion catheter:
Peripheral IV
PICC line
Dialysis access: ____________________________
Type of central line:
insertion date:
# Lumens:
Isolation precautions:
MRSA
VRE
C-Diff
Tuberculosis
other:
Date Influenza vaccine given: ___________________
Date Pneumococcal vaccine given:_______________
Physicians Involved in Care of Patient
Patient aware of diagnosis:
yes
no, explain:
Physician Name
Procedure/Service
Family/Designee aware of transfer:
yes
no, explain:
DNR:
yes
no
Significant care issues/assessments [include psychosocial, fall interventions, Braden Score, full description of skin integrity including
wounds, incision and ulcers – including size (length and depth), location, color, drainage, odor and stage, if pressure ulcer; dressing,
tubes, aspiration risk special equipment, etc.]:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Signature/Title: _________________________ Print Name: _____________________ Date: _______ Time:______
Form –B Rev. 1/1/06
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