Hospital Patient Discharge Form – Fill Out and Use This PDF

The Hospital Patient Discharge form serves as a crucial mechanism to ensure the seamless transition of care from hospital settings to subsequent care facilities, such as Skilled Nursing Facilities (SNFs) or Acute Inpatient Rehabilitation Facilities. It systematically captures vital information ranging from patient demographics, medical history, to specific care requirements, facilitating precise communication between healthcare providers. Guided by protocols set by insurance entities like Blue Cross Blue Shield, the form emphasizes the importance of thorough completion to avoid potential delays in patient care or increased financial obligations for patients.

Ensure the continuity and quality of your care by carefully filling out the Hospital Patient Discharge form. Click the button below to start the process.

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Hospital Patient Discharge Form PDF Details

The intricate process of transitioning a patient from hospital care back to their home or another facility is encapsulated within the Hospital Patient Discharge form, showcasing a comprehensive range of assessments and necessary information to ensure a smooth transition. This form, utilized by skilled nursing facilities and acute inpatient rehabilitation facilities, serves as a critical tool for communicating the patient's care needs and planning post-hospital care. It encompasses a variety of sections including facility and member information, detailed clinical information from admission details to medical history, therapy requirements, and discharge plans. Precertification and recertification processes are integral to this paperwork, emphasizing the need for accuracy and thoroughness in completion to avoid delays in processing. Importantly, this form underscores the partnership with Blue Cross and Blue Shield Association, highlighting the necessity for facilities and providers to participate with the local plan to mitigate potential increased costs for members. Key to this form are disclaimers and attestations regarding the processing time for requests, the verification of eligibility and benefits, and a clear statement that the completion of this document does not guarantee payment. This emphasizes the meticulous attention required in filling out the form, where every field demands attention, and any oversight or illegibility could lead to unprocessed submissions. Furthermore, the form incorporates significant medical details—ranging from admitting diagnosis and vital signs to a comprehensive review of the patient’s functional status and planned discharge details—ensuring a holistic view of the patient's needs and facilitating a seamless transition from hospital to the next phase of care.

Question	Answer
Form Name	Hospital Patient Discharge Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	michigan facility form, michigan acute inpatient facility, skilled nursing form, printable discharge patient registration forms

Form Preview Example

Skilled Nursing Facility,

Acute Inpatient Rehabilitation Facility

Fax Assessment Form

A nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association

Re-sending fax

Precertification

Recertification

Complete this form and fax to: 1-866-411-2573

UAW Retiree Contracts fax to: 1-866-915-9811

Facility and provider must participate with local Blue Cross Blue Shield plan or member may incur higher costs. Complete every field unless otherwise noted. Information must be legible. Place N/A if not applicable. Precertifications and Recertifications are not guarantee of payment.

Incomplete or illegible submissions will be returned unprocessed.

Disclaimer Statements and Attestation

• Please allow 24-48 hours for processing precertification and recertification requests.

•

Please verify eligibility and benefits prior to request. SNF/Rehab benefits Verified

Yes. Yes, number of days available____.

•

All therapy notes are within 24 to 48 hours of admission date or last covered date (only choose one answer)

Yes

•

SNF member is receiving at least 1 hour of therapy 5 days a week (only choose one answer)

Yes

•Acute rehab member is receiving OT or PT at least 3 hours per day, 5 days per week and able to sit for 1 hour a day (only choose one answer) Yes No

		Assessment type/coverage
Facility type:	SNF	Acute Inpatient Rehabilitation Number of days requested: 7 days 10 days 14 days ELOS (# of days)

Member/facility information


Member name		Date of birth		Address

Policy number	Member phone number		Hospital		Admission date

Admitting facility and NPI number

Facility PIN number

Phone number

Facility reviewer name

Fax number

Address

Admission Information

Clinical information/basics

Admission date to SNF/IPR

Admitting doctor (first/last name and NPI#)

Vital signs: T

Physician address/phone number

Bowel:

Continent

Incontinent

Bladder:

Continent

Incontinent

Hospital admitting diagnosis and ICD-10 CM code

Cath/Type:

NPO

Type:

Diet:

Yes

Tube feeding:

Complications

IV/PICC line:

Yes

Surgical procedure

Date

O2 delivery:

None

Type:

Yes

Sat:

Vent:

Medical history

Vent Settings:

Suction

None

Freq:

frequency/24H:

Height

Weight

Prior level of function (home)

Respiratory tx:

Yes

Freq:

Mobility current functioning

Trach:

None

Type:

Date of PT/OT notes:

Pain location:

Focus goal of physical therapy

Pain medication:

Bed mobility:

Total assist

Max assist

Mod

Min

Route

Dose

Frequency

Mod Ind

Ind

CGA

SBA

Pain scale:

Before

After

Total assist

Max assist

Mod

Min

Transfers:

management

CGA

SBA

Mod Ind

Ind

Clinical information/cognition

Gait/distance

Alert and oriented X

Other:

WF 12173 JUN 18 Page 1 of 2

Mobility current functioning (continued)

Clinical information/medications

Gait/assist

Total assist

Max assist

Mod

Min

List significant medication changes at reassessment

needed:

CGA

SBA

Mod Ind

Ind

that affect functioning:

Gait/assistive

None or

Type:

device:

Stairs:

1.) Current number of stairs can climb:

2.) Number of stairs in home:

Max assist

Mod

Min

Stairs/assist

Total assist

List IV medications (medication name, dose, frequency,

needed:

Mod Ind

Ind

start date, end date):

CGA

SBA

Comments:

Medication name

Dose

Frequency

Start date

End date

Ending date

Self-care current functioning

Clinical information/skin status

Focus occupational therapy goals:

Skin status:

Intact

If not intact, complete fields below and add pages as needed.

Wound or incision/Location and stage:

Bathing/UE:

Total assist

Max assist

Mod

Min

CGA

SBA

Mod Ind

Ind

Bathing/LE:

Total assist

Max assist

Mod

Min

Size L x W x D (CM):

CGA

SBA

Mod Ind

Ind

Dressing/UE:

Total assist

Max assist

Mod

Min

Treatment

CGA

SBA

Mod Ind

Ind

Dressing/LE:

Total assist

Max assist

Mod

Min

CGA

SBA

Mod Ind

Ind

Total assist

Max assist

Min

Wound or incision/Location and stage:

Toileting/

Mod

Hygiene mgt:

CGA

SBA

Mod Ind

Ind

Total assist

Min

ADL

Max assist

Mod

transfers:

Ind

CGA

SBA

Mod Ind

Speech therapy current status

Size L x W x D (CM):

None

Dysphagia evaluation/Modified barium swallow

Result/Aspiration risk/Recommendations:

Treatment type and frequency

Comment:

Discharge plans (must be initiated upon admission)

Discharge date (tentative)

Home evaluation date

Home/number of levels:

Other:

Discharge

Home alone

HHC/company

Family/support

Other

Home/number of steps at:

Entry:

location

Assisted living

Long-term care

Adult foster care

Bed/bath:

Equipment:

Discharge barriers:

Supervision needs:

WF 12173 JUN 18 Page 2 of 2

How to Edit Hospital Patient Discharge Form Online for Free

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Stage number 1 of completing michigan nursing facility form

2. When this part is completed, go on to enter the applicable details in all these: Policy number, Member phone number, Hospital, Admission date, Admitting facility and NPI number, Facility PIN number, Phone number, Facility reviewer name, Fax number, Address, Admission Information Admitting, Physician addressphone number, Hospital admitting diagnosis and, Complications, and Surgical procedure.

Part number 2 for filling in michigan nursing facility form

3. The following portion focuses on Height, Weight, Prior level of function home, Mobility current functioning, Date of PTOT notes Focus goal of, Bed mobility, Transfers, Gaitdistance, Total assist CGA Total assist CGA, Max assist SBA Max assist SBA, Mod Mod Ind Mod Mod Ind, Min Ind Min Ind, WF JUN Page of, Suction frequencyH, and None or - fill out each one of these fields.

michigan nursing facility form writing process described (part 3)

People who use this PDF often get some things incorrect while filling in None or in this section. Remember to revise everything you type in here.

4. To move ahead, this fourth stage will require filling in a few blank fields. Examples of these are Gaitassist needed, Gaitassistive device, Stairs, Stairsassist needed, Comments, Mobility current functioning, Total assist CGA, Max assist SBA, Mod Mod Ind, Min Ind, Clinical informationmedications, List significant medication, None or, Type, and Current number of stairs can climb, which you'll find fundamental to going forward with this particular PDF.

Max assist SBA, Min Ind, and Mod Mod Ind of michigan nursing facility form

5. To conclude your document, this particular section incorporates a number of extra fields. Entering BathingUE, BathingLE, DressingUE, DressingLE, Toileting Hygiene mgt, ADL transfers, Total assist CGA Total assist CGA, Max assist SBA Max assist SBA Max, Mod Mod Ind Mod Mod Ind Mod Mod, Min Ind Min Ind Min Ind Min Ind, Size L x W x D CM, Treatment, Wound or incisionLocation and stage, Speech therapy current status, and Size L x W x D CM will certainly wrap up everything and you'll certainly be done in no time!

How to complete michigan nursing facility form step 5

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Hospital Patient Discharge Form – Fill Out and Use This PDF

Hospital Patient Discharge Form PDF Details

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