h o s p i t a l c h a r t r e v i e w f o r m- national p o l s t（h o s p i t l c h r t r e v i f e w o r m -国家p l o s t）（6页）.doc

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2017-01-23 发布于四川
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h o s p i t a l c h a r t r e v i e w f o r m- national p o l s t（h o s p i t l c h r t r e v i f e w o r m -国家p l o s t）（6页）.doc

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h o s p i t a l c h a r t r e v i e w f o r m- national p o l s t（h o s p i t l c h r t r e v i f e w o r m -国家p l o s t）（6页）

OR HOSPITAL CHART REVIEW FORM 1. Today’s Date _________________________ 2. Age in Years ________ 3. Gender ( Female ( Male 4. Race/Ethnicity: ( White ( African American/Black ( Native Hawaiian/Pacific Islander ( Asian ( American Indian/Alaskan Native ( Hispanic ( Other ( not available 5. Education ( No Schooling ( 8th Grade/less ( 9 – 11th grades ( High School ( Technical/trade school ( some college ( Bachelor’s degree ( Graduate degree ( not available 6. Discharge destination ( Bethany St. Joseph’s ( Bethany Riverside ( Hillview ( St. Joseph’s ( Onalaska Care ( Mulders ( Lakeview ( Rolling Hills ( Morrow Home 7.Admission/Discharge: Primary reason for hospitalization_____________________________________ Reason for discharge to nursing home □ rehabilitation □ long term care □ other ___________ Is this a new discharge to a nursing home? □ yes □ no Did the resident have a POLST at admission to the hospital? □ yes □ no If the resident had a POLST at admission, was the POLST changed at discharge? ( yes ( no ( not applicable 8. Primary service admitted to:__________________________________________ Discharge Service: _________________________________________________ Date of admission_________________ Date of Discharge __________________ HOSPITAL PREFERENCES, ORDERS, LIFE-SUSTAINING TREATMENTS 9. PREFERENCES: Is there evidence of a discussion about treatment preferences in the chart at discharge: □ yes □ no If yes, describe: Date of Discussion Staff involved? Identify. Patient/family involved? Identify. Was surrogate authorized? If so, describe role. a. Where is this documented? ______________________________________ b. Who documented the discussion? _________________________________ c. Length of discussion □ 0-15 min. □ 15-30 min. □ 30-45 min □ no time listed d. What was discussed? Please