Medical Care Referral Form
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1MEDICAL CARE REFERRAL FORM
USE IN ALL SITUATIONS WHEN A RESIDENT HAS A NEW PROBLEM AND INFECTION MAY BE SUSPECTED, AND IS BEING
REFERRED TO A MEDICAL CARE PROVIDER, INCLUDING TRANSFER TO AN EMERGENCY DEPARTMENT OR HOSPITAL.
To: _______________________________________________ Phone: ________________ Fax: _________________
Resident Name: _________________________________________ DOB: __ __/__ __/__ __ Room #: _______________
From:____________________________________Phone ______________________Date:___________Time__________
Family Contacted: Yes No
If YES, Name and relationship:_____________________Contact Date_______Time_________
DESCRIPTION OF CURRENT PROBLEM including recent fever pattern and change in recent/current health status:
CURRENT VITAL SIGNS
USUAL COGNITIVE FUNCTION
MEDICAL HISTORY
Diabetes:
Yes
No ?
Blood pressure: _____________________
Good
Questionable
Impaired
If Yes, most recent blood sugar:________
Pulse:
_____________________
RECENT/CURRENT HEALTH STATUS
COPD:
Yes
No ?
Respiratory rate: _____________________
New or worsening confusion
Yes
No
?
Indwelling catheter:
Yes
No ?
Highest temperature
New or worsening agitation
Yes
No
?
On hospice care:
Yes
No ?
in last 24 hours: ____________________
Decrease in eating or drinking
Yes
No
?
Advanced directive/
How taken: _________________________
Sleepiness/decreased alertness
Yes
No
?
MOST Form:
Yes
No ?
3 most recent routine temperatures
Decline in function
Yes
No
?
DNR
Yes
No ?
and how taken:
No Antibiotics
Yes
No ?
Temp
How taken:
Fall
Yes
No
?
MEDICATION ALLERGIES:
Yes
No ?
If Yes:
_____________
__________________
List:____________________________________
Witnessed
Yes
No
?
_____________
__________________
_______________________________________
Hit head
Yes
No
?
_______________________________________
_____________
__________________
Lost consciousness
Yes
No
?
_______________________________________
Shaking chills in
Suspected minor injury
Yes
No
?
last 24 hours:
Yes No ?
Suspected serious injury
Yes
No
?
Put an “X” in the box to indicate the suspected infection and circle related signs/symptoms Y (present), or No (not present), or ? (not known).
o
o
Suspected Respiratory Infection
Suspected Urinary Tract Infection
Y N ?
New or increased urgency of urination
Y N ?
New cough
Y N ?
Increasing cough
Y N ?
New or increased frequency of urination
Productive cough
Y N ?
New or increased suprapubic tenderness
Y N ?
If yes, with purulent sputum:
Y N ?
Y N ?
Costovertebral angle (CVA) tenderness
If yes, new onset:
Y N ?
Y N ?
Sore throat
If yes, increasing:
Y N ?
Chest X-ray
Y N ?
If yes, pneumonia infiltrate:
Y N ?
Y N ?
Painful or difficult urination
Y N ?
Obvious blood in urine
Y N ?
Body aches
Y N ?
Headache
Y N ?
Change in urine appearance or odor
Y N ?
Runny nose and/or sneezing
Y N ?
New or worse urinary incontinence
Y N ?
Shortness of breath
Y N ?
Positive culture
If yes, positive for:_______________________________
Y N ?
Pleuritic chest pain (painful to take deep breath)
o
Suspected Skin or Soft Tissue Infection
O2 saturation, baseline: ________%
Location:
Y N ?
New or increasing pus draining from wound
O2 saturation, current: ________%
o
Y N ?
New breakdown
Suspected Gastrointestinal Infection
Y N ?
New or expanding redness around wound
Y N ?
Vomiting: Number of times in past 24 hours: _______
Y N ?
Pain / tenderness
Y N ?
Diarrhea: Number of times in past 24 hours: _______
Y N ?
Warmth
Y N ?
Other vomiting or diarrhea in the community
Y N ?
New or increased swelling at the site
Y N ?
Positive culture
Y N ?
Increased odor
If yes, positive for:_______________________________
Y N ?
Ulcer for 3 or more weeks
PREVENT
HAIs
May 2014
Agency for Healthcare Research and Quality
Healthcare-
Associated
AHRQ Pub. No. 14-0011-2-EF
Advancing Excellence in Health Care
Infections
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