Fillable Printable Clinical Transition Plan - Illinois
Fillable Printable Clinical Transition Plan - Illinois
Clinical Transition Plan - Illinois
State of Illinois - Department of Human Services
Clinical Transition Plan
IL462-4000 (N-4-11)
Page 1 of 8
PURPOSE: To Facilitate the continuity of care for an individual transitioning to alternate placement. The
Clinical Transition Plan is intended to supplement the Transition Plan by providing more detailed
information relative to the clinical issues.
COMPLETED BY: Professional Nurses and Primary Care Physicians
GENERAL INFORMATION:
1. The entire form is to be completed by a professional nurse, designated by the Director of Nursing,
and a Primary Care Physician.
2. The original is to be filed in the medical record with a copy retained by the Habitation Plan
Coordinator (HPC) and the designated nurse.
3. When changes to a section occur, the section is to be updated by the designated nurse and/or the
Primary Care Physician with a newly completed page and placed in the Clinical Transition Plan in
the proper order. The HPC and designated nurse will each retain a copy. The old section should
be removed.
4. The Clinical Transition Plan will be reviewed prior to discharge to ensure accuracy. The designated
nurse will be responsible for informing the Primary Care Physician that the plan requires updating.
5. The HPC is responsible for ensuring this document is provided to the potential provider when visits
are scheduled.
PROCEDURE
1. The Clinical Transition Plan will be initiated when an individual's name is placed on Tier 1. This Plan
will be completed prior to the individual visiting a potential community provider.
2. Sections I through IV and Section VI (Nursing) are to be completed by the designated nurse.
3. Section V and Section VI (Physician) are to be completed by the Primary Care Physician.
4. Section VII is to be completed by the designated nurse when the supporting clinical documents are
attached to the Clinical Transition Plan packet.
5. The primary care physician and the designated nurse are to sign and date when their sections are
completed.
INSTRUCTIONS
1. May use (TAB) key to move forward from field to field and (SHIFT) (TAB) to move back from field to
field.
2. May use (ENTER) key to "check" a box.
3. NOTE: If you cannot read all of what you typed in a section (there may be a "+" sign at the end of
the typing), only what you can read will be printed.
State of Illinois - Department of Human Services
Clinical Transition Plan
IL462-4000 (N-4-11)
Page 2 of 8
SECTION I. General Demographics/Information - Completed by Nursing
Name: DHS ID Number:
Age: Date of Birth:
Gender:
Female Male
Race: Verbal Skills:
Hearing Ability: Visual Ability:
Communication:
SECTION II. General Medical Information - Completed by Nursing
Normal Gait
Non Ambulatory Abnormal gait, Does not require assistance
Abnormal gait, Requires personal assist Abnormal gait, Requires physical device
Abnormal gait, Requires physical device and personal assist
Type of Device
W/C
Independent
Mechanical device
SBA
Cane
Type:
Total lift
Hand on assist of
staff
Other:
Walker Type:
1. Ambulation
2. Bowel Managment
Self toilets
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No
Yes No
Yes No
NoYes
Yes No Yes No
NoYes
Yes No
Yes No
Yes No
Yes No
Yes No
Requires assistance Ostomy
Continent of bowel Diagnosis of constipation
History of bowel obstruction History of bowel perforation
History of bowel surgery/procedure
Date/Type:
Requires frequent bowel aids (greater than monthly)
3. Aspiration Risk
Is the individual at risk for aspiration?
Type of Risk:
GERD Sialorrhea Oral-pharyngeal dysmotilty Gastroesophageal dysmotility
Diaphragmatic hernia Other:
Has the individual had a Video Swallow Evaluation?
Date completed:
4. Fall Risk
Is the individual at risk for a fall? Has individual fallen in the past 12 months?
Has the individual sustained a fracture from a fall or unknown mechanism?
Does the individual have a servous orthopedic risk factor?
Moderate to Severe osteoarthritis Rheumatoid arthritis Degenerative spine disease
Kyphosis Scoliosis Internal orthopedic appliance (artificial joint, stabilizing rod, etc.)
Other:
5. Pulmonary Risk
Does the individual have serious pulmonary risk factors?
COPD Asthma Recurrent Pneumonia Other
Respiratory Therapy
Details:
The individual requires
Bi-Pap
C-Pap
Oxygen Other
Other:
Is there a medical condition that may cause imbalance?
CP Arthritis Parkinson's
De-conditioned Cardiovascular Abnormal Vision Other:
State of Illinois - Department of Human Services
Clinical Transition Plan
IL462-4000 (N-4-11)
Page 3 of 8
Yes No
Does this person have serious Neurologic risk factors?
6. Neurological Risk
Stroke Small Vessel Disease Dementia Hydrocephalus Tardive Dyskinesia
Parkinson's Prolapsed Disk Spinal Stenosis Spasticity Dystonia Other
Yes No
Active Seizure Disorder
Yes No
History of seizure disorder
Type of Seizures:
Frequency of Seizures (average/month): Duration of Seizure Activity (average in minutes):
Date of Last Seizure:
Does individual have a VNS?
Yes No
Yes No
Will PRN medications be required for management of seizure control?
If "Yes", name/dose/route of medication:
7. Cancer Risk
Yes No
Yes No Yes No
Yes No
Yes No
Yes No
Yes No
NoYes
Yes No
Yes No
Does the individual have cancer or a history of cancer?
If "yes", Describe type and treatment provided:
8. Administration of Medication
Are there special considerations required for administration of medications?
Compliance issues Enteral tube Other:
9. Nutritional
Ideal body weight: Current weight: BMI: Height:
Individual is underweight: Individual is overweight:
G-Tube
Type & Size:
J-Tube
Type & Size:
Type & Size:
Other
Diet Order:
Etiology of abnormal weight:
10. Skin Integrity
Is the individual at risk for skin breakdown?
Etiology/Treatment:
Chronic wounds:
Etiology/Treatment:
Preventative Measures/Alternate Positioning
List:
11. Infection Control
Does the individual have an active infectious disease condition?
MRSA MDRO C-diff Pseudomonas Other (List):
Location/details:
Is the individual colonized with MRSA:
Location:
12. Diabetes
Does the individual have diabetes?
Insulin dependent Non-insulin dependent
A1C: Date: Value: Diet:
Medication(s):
Sliding Scale:
State of Illinois - Department of Human Services
Clinical Transition Plan
IL462-4000 (N-4-11)
Page 4 of 8
Yes No
NoYes
Yes No
NoYes
Yes No
Yes No
Does the individual have chronic cardiovascular risk?
13. Cardiovascular Risk
Hypertension Arrhythmias CAD CHF Other:
14. Dental Issues
Abscess Caries Edentulous Dentures Peridontal Disease
Other
15. Allergies/Adverse Drug Reactions/Sensitivities
Does the individual have any adverse drug reactions/allergies?
If "Yes", list below, include type of reaction and date (if known):
ADR: Allergy: Sensitivity:
SECTION III. Medical Follow-up - Completed by Nursing
In the past year, has the individual been admitted to an acute facility/emergency room for medical condition?
1. Hospitalization/Clinical Follow-up
Date: Facility: Reason:
Reason:Facility:Date:
Reason:Facility:Date:
Reason:Facility:Date:
If more room is needed attach a separate sheet of paper.
2. Implanted Devices
Does the individual have an implanted device?
VNS:
Date inserted: Date last battery change:
Baclofen Pump:
Date inserted: Date last fill:
Pacemaker:
Date inserted: Date last battery change:
Portacath:
Date inserted: Date last flush:
Foley Catheter:
Date inserted: Last changed:
Catheter size:
3. Adaptive or Specialized Equipment
Does the individual require adaptive or specialized equipment (not previously listed)?
Glasses Hearing Aide
R: L: Both:
Adaptive eating utensils:
Type:
Other:
4. Protective devices?
Does the individual require protective devices?
Type:
5. Medical and Dental Support Services
Medical immobilization (Type & Indication):
Anxiolysis (Medication, Indication, Dose):
Desensitization Program:
If "Yes", attach support desensitization document.
Yes No
State of Illinois - Department of Human Services
Clinical Transition Plan
IL462-4000 (N-4-11)
Page 5 of 8
SECTION IV. Status of Consultative Services - Completed by Nursing
Yes No
Cardiology
Specialist Name: Telephone:
Reason for Service:
Frequency of Service:
Last Date of Services:
Contact Information:
Recommended appointment date: Actual appointment date:
Yes No
Yes No
Yes No
Dental Services
Specialist Name: Telephone:
Reason for Service:
Frequency of Service:
Last Date of Services:
Contact Information:
Recommended appointment date: Actual appointment date:
ENT
Specialist Name: Telephone:
Reason for Service:
Frequency of Service:
Last Date of Services:
Contact Information:
Recommended appointment date: Actual appointment date:
Gynecologist
Specialist Name: Telephone:
Reason for Service:
Frequency of Service:
Last Date of Services:
Contact Information:
Recommended appointment date: Actual appointment date:
Yes No
Yes No
Yes No
Hematologist
Specialist Name: Telephone:
Reason for Service:
Frequency of Service:
Last Date of Services:
Contact Information:
Recommended appointment date: Actual appointment date:
Neurologist
Specialist Name: Telephone:
Reason for Service:
Frequency of Service:
Last Date of Services:
Contact Information:
Recommended appointment date: Actual appointment date:
Oncologist
Specialist Name: Telephone:
Reason for Service:
Frequency of Service:
Last Date of Services:
Contact Information:
Recommended appointment date: Actual appointment date:
State of Illinois - Department of Human Services
Clinical Transition Plan
IL462-4000 (N-4-11)
Page 6 of 8
Yes No
Yes No
Optometrist
Specialist Name: Telephone:
Reason for Service:
Frequency of Service:
Last Date of Services:
Contact Information:
Recommended appointment date: Actual appointment date:
Othopedist
Specialist Name: Telephone:
Reason for Service:
Frequency of Service:
Last Date of Services:
Contact Information:
Recommended appointment date: Actual appointment date:
Yes No
Podiatrist
Specialist Name: Telephone:
Reason for Service:
Frequency of Service:
Last Date of Services:
Contact Information:
Recommended appointment date: Actual appointment date:
Yes No
Psychiatrist
Specialist Name: Telephone:
Reason for Service:
Frequency of Service:
Last Date of Services:
Contact Information:
Recommended appointment date: Actual appointment date:
Yes No
Yes No
Other
Specialist Name: Telephone:
Reason for Service:
Frequency of Service:
Last Date of Services:
Contact Information:
Recommended appointment date: Actual appointment date:
Other
Specialist Name: Telephone:
Reason for Service:
Frequency of Service:
Last Date of Services:
Contact Information:
Recommended appointment date: Actual appointment date:
State of Illinois - Department of Human Services
Clinical Transition Plan
IL462-4000 (N-4-11)
Page 7 of 8
SECTION V. Medical/Physical Issues - Completed by Physician
Medical/Physical Problem Status of Medical/Physical Problem
Follow-up action for clinically significant
medical problems (lab tests, evaluations,
medication changes, etc.)
Physician: List and define any additional significant health care precautions to support this individual's needs that are not
addressed previously.
Nurse: List and define any additional health care precautions to support this individual's needs that are not addressed
previously.
SECTION VI. Additional Significant Health Issues
State of Illinois - Department of Human Services
Clinical Transition Plan
IL462-4000 (N-4-11)
Page 8 of 8
SECTION VII. Supporting Clinical Documents
Supporting Clinical Documents (Check Box when in Transition Packet)
History and Physical
Health Risk Screen Tool (HRST)
Immunization Record
Last DISCUS
Transition Plan
Medical Consultation Reports
Psychiatric Consultation Reports
Current Medication Administration Record (MAR)
Diagnostics (all MRI/CT Scans, past 24 months EEG, X-Rays, Sleep Studies, VFS, Other relevant studies)
Cardiology
Hematologist
Orthopedist
Dental
Neurologist
Podiatrist
ENT
Oncologist
Psychiatrist
Gastroenterologist
Ophthalmologist
Pulmonologist
Gynecologist
Optometrist
Other
Other
Date completed:
Physician Signature: Date:
Registered Nurse Signature: Date:
