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Psychosocial Checklist   Discharge Planning   Quality Reflection

Pt Name / DOB:			Initial working diagnosis:                                                                     Admit date:
CC                                                                                                                    Date			/	/	/	/	/	/	/
Home meds               Reconciled (   )		Last 24hrs:   Key Events
1                                                 (   )
2                                                 (   )
3                                                 (   )		Today:  key physical findings
4                                                 (   )		Today:  key labs
5                                                 (   )		Today: key radiology
6                                                 (   )		To do:
7                                                 (   )		To do:
8                                                 (   )		Spoke to primary nurse (events/plan)	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N
9                                                 (   )		Blood Pressure (Maximum)	/	/	/	/	/	/	/
10                                               (   )		Controlled?	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N
11                                               (   )		Glucose Control	Min	Min	Min	Min	Min	Min	Min
12                                               (   )			Max	Max	Max	Max	Max	Max	Max
13                                               (   )		Glucose controlled? >80 and <180	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N
14                                               (   )		PLAN reviewed: patient (P) / family (F)	P    /     F	P    /     F	P    /     F	P    /     F	P    /     F	P    /     F	P    /     F
15                                               (   )		Fall risk minimized (meds, fluids etc)	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N
16                                               (   )		Pain controlled	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N
17                                               (   )		Activity maximized (w/correct order)	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N
Contact info	Tel Number	Out of bed in last 24hrs?  Consider PT	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N
Family #1		Pressure ulcer present (P), Risk reduced	P    Y   /   N	P    Y   /   N	P    Y   /   N	P    Y   /   N	P    Y   /   N	P    Y   /   N	P    Y   /   N
Family #2		Foley present (F), Remove today	F    Y   /   N	F    Y   /   N	F    Y   /   N	F    Y   /   N	F    Y   /   N	F    Y   /   N	F    Y   /   N
PCP		Central line present (C), Remove today	C    Y   /   N	C    Y   /   N	C    Y   /   N	C    Y   /   N	C    Y   /   N	C    Y   /   N	C    Y   /   N
Social worker		PO Intake  Poor(P), Avg (A), Excellent (E)	P    A     E	P    A     E	P    A     E	P    A     E	P    A     E	P    A     E	P    A     E
Case manager		Nutrition orders optimized	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N
Other		VTE prophylaxis ordered / delivered
Abington Memorial Hospital.                                                             Comments on this card?    Doron Schneider, MD  dschneider@amh.org

Back of Card

Pt Name / MR#                                                                                                       Date			/	/	/	/	/	/	/
Teaching Elements		Observed by: Att  / Res/Int,  Hist / Phys	A / R   H / P	A / R   H / P	A / R   H / P	A / R   H / P	A / R   H / P	A / R   H / P	A / R   H / P
My Attending:		I presented this patient today	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N
My Resident:		Feedback provided on notes today	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N	Y    /    N
My Intern:		Learning today
Psychosocial Issues			Notes:  HPI / PE / Problem List Etc
Lives at (home/NH etc)
Lives with
Employment status (job / type etc)
Does patient have regular PCP follow up
What is the patient's support system?
Do literacy/numeracy issues affect care?
Med adherance problems?  If so, why?
Do med insurance issues impact pts care?
Communication / learning  barriers:
The patient as person (life story etc)
Substance abuse (ETOH etc) affect health
Discharge Planning		Special needs at discharge                                                                                                                                      Med Rec Done at DC (Y/N)
Readmission risks (circle all)		Major threat for readmission:
(>2 = high rsk):  Problem meds (DM, narcs,anticoags etc), Punk (depression), Principle dx (CA, COPD, DM, CHF), Polypharmacy (>5), Poor health literacy (No Teach Back),  Prior hospitalization (6M)
Quality of Care    (www.qualitymeasure.ahrg.gov, or  guideline.gov, or innovations.ahrq.gov/qualitytools)						What systems did you see in place to ensure that we delivered appropriate care for this patients primary condition		#	#
Primary diagnosis  (Why hospitalized):								#	#
Pertinent Quality Metrics:								#	#
Did we provide good care :						Examples:  1) Redundant steps/staff, 2) audit and feedback, 3) order sets, 4) guidelines, 5) policies, 6) clinical alerts, 7) patient clustering, 8) registry, 9) chart reminders, 10) checklists, 11) desired action default, 12) standardization etc
In caring for this patient I grew as a clinician by:
Abington Memorial Hospital.       Return this completed card to: