Transition of Care Summary

s/p [select value="Hospital|SNF"] from [text size="10"] to [text size="10"] 
Reason for Hospitalization: [text size="50"]
Discharge Summary Reviewed: [select value="Yes|No"]
Disease management details (if applicable):
-CHF, Weight on Discharge: [text size="10"]
-COPD: Rescue Inhaler / Maintenance Inhaler 
Reviewed Warning signs such as: (note if patient self-management documents utilized) [text size="50"]
Any Med Changes: [text size="50"]
	New Meds Prescribed including Antibiotics: [text size="50"]
	Meds Discontinued or dose changes: [text size="50"]
Meds List Updated: [select value="Yes|No"] 
PPS changes (s/p Discharge condition - any change in PPS from before): [text size="50"]
Updated Risk Stratification: [text size="50"]
DME/ Labs: (Needed or Ordered): [text size="50"]
CHHA Service Communication Person Name & #: [text size="50"]
Note if PT/OT in home: [text size="50"]
GOC/ACP (any changes): [text size="50"]
PCP/ Specialist F/up (when): [text size="50"]
Prospero next F/up Appt: [text size="50"]
s/p from to
Reason for Hospitalization:
Discharge Summary Reviewed:
Disease management details (if applicable):
-CHF, Weight on Discharge:
-COPD: Rescue Inhaler / Maintenance Inhaler
Reviewed Warning signs such as: (note if patient self-management documents utilized)
Any Med Changes:
New Meds Prescribed including Antibiotics:
Meds Discontinued or dose changes:
Meds List Updated:
PPS changes (s/p Discharge condition - any change in PPS from before):
Updated Risk Stratification:
DME/ Labs: (Needed or Ordered):
CHHA Service Communication Person Name & #:
Note if PT/OT in home:
GOC/ACP (any changes):
PCP/ Specialist F/up (when):
Prospero next F/up Appt:

Result - Copy and paste this output:

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