Refer a Patient

Person Making Regerral

Phone

Facility

Patient Name

DOB

SS#

Managed Care CM or Hospital CM Contact*

Phone & Ext.*

Reason For Referral*

Primary Diagnosis*

Special Treatments: i.e wound care, PT,IV ABTs*

Medical Records: Admit H&P and Recent:

MAR & Medications on Discharge (reconciliation)

Labs & X-Rays & Diagnostic Studies

MD Progress notes

Discharge Orders The field is required.

Other Records:

ADLs & Special Needs

Yes

Recent Falls

Yes

Continent

Yes

If Incontinent, can Change own Diaper

Yes

Continent

Yes

Is Patient Ambulatory

Yes

If not Ambulatory, Independent with Mobility

Yes

Is Patient Competent

Yes

History of Dementia or Alzheimer’s

Yes

History of MRSA or Other Isolation

Yes

History of Recent Substance Use

Yes

Signs of Withdrawal

Yes

Is Patient on Methadone

Yes

Psych Diagnosis

Yes

Is patient receiving psychiatric care

Yes

Public Health Disclosure TB. All displaced persons are at risk for TB. Any displaced person with a new cough or change in cough for three weeks or with pulmonary symptoms suggestive of pneumonia.
Must have CXR. There is a rise in the incidence of communicable diseases. In order to effectively manage client illnesses, CMIS requires that you report communicable diseases. This includes but is not limited to TB, VRE, MRSA, C-DIFF. If a patient has been identified to have scabies it is required that they have undergone treatment and have been cleared prior to admitting to the CMIS Program.
Admission Criteria: 1. Must have a primary medical problem 2. Must be physically and psychiatrically stable to receive care in a medical respite setting 3. Must be in need of short term recuperative care 4. Must be able to participate in ADLs 5. If on Methadone must be in a Methadone Program 6. Must be mentally competent
Exclusion Criteria: 1. Incomplete treatment of Scabies 2. Unable to transfer or perform ADLs 3. C. diff / MRSA / TB 4. Dementia/Memory Loss 5. Combative/Violent behavior 6. Hallucination/Delusion 7. Psychiatrically Unstable 8. Unable to self-represent 9. Unable to perform ADL and transfer with assistance

Length of respite stay (projected)

Interpreter Language Needed:

Other Communications from Assessing or Referring Representative:

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Face sheet, H&P, Meds, PT/OT, Social Service Evaluations, Current MD progress notes, Chest Xray or TB clearance

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REFER A PATIENT

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