BIRCH HOSPITAL
DEMO DOCUMENTCare transitions & discharge planning
POST-ACUTE REFERRAL
Transition summary
Reason for referral
Post-operative recovery following hip fracture repair. Referral for skilled nursing rehabilitation and support with the transition from hospital care.
Identified care needs
- Skilled nursing and rehabilitation
- Physical and occupational therapy
- Wound monitoring
- Medication management
Transition plan
Accepted by Maple Grove Skilled Nursing & Rehab. Bed 214B held for September 10, with estimated arrival at 11:30 AM.
Pending final review
Medication reconciliation to be confirmed by the care team before or at admission.