SEATTLE ASSISTED LIVING NETWORK
Discharge Planner — Referral Checklist
________________________________________________

Complete what you can. The more you can share up front,
the faster we can match. Call the direct line if you have
questions: (425) 400-3202

1.  FACE SHEET
    Patient name, date of birth, demographics, current
    location (hospital / unit), primary contact.

2.  HISTORY AND PHYSICAL
    Current H&P or recent discharge summary.

3.  MEDICATION LIST
    Current medications, dosages, and schedule.

4.  CURRENT NURSING NOTES
    Recent nursing notes describing the patient's current
    condition and needs.

5.  MOBILITY AND TRANSFER STATUS
    Ambulation, transfers (independent / one-assist /
    two-assist / mechanical lift), fall risk.

6.  EQUIPMENT NEEDS
    Ventilator, tracheostomy, feeding tube (G-tube/J-tube),
    oxygen, specialty bed, Hoyer lift, suction, etc.

7.  RESPIRATORY NEEDS
    Vent settings, oxygen requirements, trach care,
    nebulizer, CPAP/BiPAP, suctioning frequency.

8.  DIALYSIS SCHEDULE
    Dialysis modality, center, and days/times if applicable.

9.  ISOLATION STATUS (IF APPLICABLE)
    Any contact / droplet / airborne precautions or active
    infection requiring isolation.

10. BEHAVIORAL / SAFETY FACTORS
    Cognitive status, wandering, agitation, elopement risk,
    behavioral support needs.

11. PAYER / FUNDING INFORMATION
    Medicaid (COPES), private pay, LTC insurance, VA
    benefits, PDN eligibility, or pending determination.

12. REQUESTED DISCHARGE TIMEFRAME
    Target discharge date and urgency.

________________________________________________
PRIVACY NOTE
Do not email protected health information (PHI) to our
general inbox. For referrals containing PHI, call the
direct line at (425) 400-3202 and our team will walk you
through the intake process.