Clinical Transition Plan - Illinois

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:
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