Snf Root Cause Analysis Template: Chart Review Of Unplanned Transfers printable pdf download

SNF Root Cause Analysis:

Chart Review of Unplanned Transfers

Patient Information

Medical record #: _________________________________ Unit: __________________________________

Resident name: ___________________________________________________________________________

Date of most recent admission to nursing facility: ______________________________________________

Date of unplanned transfer: ____________ Time of unplanned transfer: ____________ (Military Time)

Reason for transfer: _______________________________________________________________________

__________________________________________________________________________________________

72 Hours Prior to Transfer

The following signs, symptoms or conditions were present:

Fever _____________________________________________________________________________

Change of mental status ____________________________________________________________

Decreased oral intake

______________________________________________________________

Change in medications ______________________________________________________________

Increased pain/pain medication requirement __________________________________________

Family mention of change of condition

_______________________________________________

Signs & symptoms of UTI ___________________________________________________________

Signs & symptoms of SOB ___________________________________________________________

Change in vital signs _______________________________________________________________

One or more falls __________________________________________________________________

Actions Taken Prior to Transfer

Was a physician or nurse practicioner (NP) contacted prior to transfer?

Yes

Was the patient evaluated by a physician or NP within 72 hours of transfer?

Yes

Was the transfer due to a lack of diagnostic services?

Yes

Was the transfer due to a lack of therapeutic services?

Yes

Medication: specifically ____________________________________________________________________

Lab tests: specifically ______________________________________________________________________

Diagnostic tests: specifically ________________________________________________________________

Snf Root Cause Analysis Template: Chart Review Of Unplanned Transfers