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ASSESSMENT OF RISK FACTORS FOR HOSPITALIZATION AND EMERGENT CARE
Prior Pattern - Check all that apply
Hospitalizations or ER visits in the past 12 months
History of falls
History of noncompliance
Chronic conditions - Check all that apply (M0230/M0240)
CHF
Diabetes
HIV/AIDS
Chronic skin ulcers
Neoplasm as primary diagnosis
COPD
"New" diagnosis/problem
Risk Factors - Check all that apply
Discharged from hospital or skilled nursing facility (M0175)
More than two secondary diagnoses (M0240)
Low socioeconomic status or financial concerns
Lives alone (M0340)
Help with managing medications needed (M0780)
Confusion (M0570)
Short life expectancy (M0280)
Poor prognosis (M0260)
Dyspnea (M0490)
Urinary catheter (M0520)
Open wound (M0440)
Total of checked boxes_____________
(6 or more boxes checked indicates high risk for emergent care)
Disciplines presently involved in patient's care:
q SN q PT q OT q ST q HHA q MSW
Patient name:__________________________________________________ Date:_______________
Staff signature:______________________________________________________________________
Source: Designed by Georgia Medical Care Foundation and available at www.medqic.org ...quot; select "Home Health," then select "Tools."
