Clinical Transition Plan - Illinois

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:
Page 3/8
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