SELECT *, patient.Last_Name_M0040 AS Last_Name, patient.First_Name_M0040 AS First_Name, patient.Middle_Initial_M0040 AS Middle FROM #Request.prefix_db_agency#.Assessment_New INNER JOIN #Request.prefix_db_agency#.patient ON (Assessment_New.Patient_ID=patient.Patient_ID) WHERE Assessment_New.Assessment_ID='#session.cs.AssessmentId#' select Last_Name, First_Name from #Request.prefix_db_lookup#.Employee where Employee_ID = '#DeathForm.Record_Created_By#' SELECT * FROM #Request.prefix_db_lookup#.Assessment_Questions_lookup JOIN #Request.prefix_db_lookup#.Assessment_Answer_lookup ON Assessment_Answer_lookup.question_id = Assessment_Questions_lookup.id WHERE Assessment_Answer_lookup.Deleted <> 1 AND Assessment_Questions_lookup.assessment_reason = '7 - Transferred to an inpatient facility - patient discharged from agency' AND (Assessment_Questions_lookup.questions like 'GG0%' OR Assessment_Questions_lookup.questions like 'J1%') GROUP BY Assessment_Answer_lookup.answer_label ORDER BY Assessment_Questions_lookup.order_id ASC

Transfer with Discharge OASIS Assessment #DeathForm.Last_Name#, #DeathForm.First_Name# #DeathForm.Middle# #DeathForm.First_Name_M0040# #DeathForm.Last_Name_M0040# SOC Date #DateFormat(DeathForm.Start_of_Care_M0030,"mm/dd/yyyy")# 7 - Transfer with Discharge Certification #DateFormat(DeathForm.Certification_Start,"mm/dd/yyyy")# to #DateFormat(DeathForm.Assessment_Completed_M0090,"mm/dd/yyyy")# Completed by #GetE.Last_Name# #GetE.First_Name#

CLINICAL RECORD ITEMS (M0080) Discipline of Person Completing Assessment: #DeathForm.Person_Complete_M0080# (M0090) Date Assessment Completed: #DateFormat(DeathForm.Assessment_Completed_M0090,"mm/dd/yyyy")# PATIENT HISTORY AND DIAGNOSES (M1041) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year's influenza season (October 1 through March 31) during this episode of care? #DeathForm.M1040_Influ# (M1046) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason: #DeathForm.M1045_Influ# (M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example, pneumovax)? #DeathForm.M1050_Pneu# (M1056) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason: #DeathForm.M1055_Pneu# RESPIRATORY STATUS (M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure , did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment? #DeathForm.M1500_Symptoms# (M1510) Heart Failure Follow-up: I patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.) #DeathForm.M1510_Hrt_FU# Transfer with Discharge Page 1

#DeathForm.First_Name_M0040# #DeathForm.Last_Name_M0040# 7 - Transfer with Discharge Completed #DateFormat(DeathForm.Assessment_Completed_M0090,"mm/dd/yyyy")# MEDICATIONS (M2004)(M2005) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issLes? #DeathForm.M2004_Med_Int# (M2015)(M2016) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur? #DeathForm.M2015_Drug_Edu# EMERGENT CARE (M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)? #DeathForm.Emergent_Care_M0830# (M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.) #DeathForm.Emergent_Care_Reason_M0840# DATA ITEMS COLLECTED AT TRANSFER/DISCHARGE ONLY (M2400) Intervention Synopsis: (deck only one box in each row.) Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? a.Diabetic foot care #DeathForm.M2400a_Diabetic# b.Falls prevention interventions #DeathForm.M2400b_FallsPrev# c.Depression intervention #DeathForm.M2400c_Depress# d.Intervention(s) to monitor and mitigate pain #DeathForm.M2400d_Pain# e.Intervention(s) to prevent pressure ulcers #DeathForm.M2400e_PressUlc# f.Pressure ulcer treatment based on principles of moist wound healing #DeathForm.M2400f_PressUlcMoist# (M2410) To which Inpatient Facility has the patient been admitted? #DeathForm.Inpatient_Facility_M0855# Transfer with Discharge Page 2

#DeathForm.First_Name_M0040# #DeathForm.Last_Name_M0040# 7 - Transfer with Discharge Completed #DateFormat(DeathForm.Assessment_Completed_M0090,"mm/dd/yyyy")# (M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? #DeathForm.Hospital_Reason_List_M0895# (M2440) For what Reason(s) was the patient Admitted to a Nursing Home? #DeathForm.Nursing_Home_M0900# (M0903) Date of Last (Most Recent) Home Visit #DateFormat(DeathForm.Date_Most_Recent_M0903,"mm/dd/yyyy")# (M0906) Discharge/Transfer/Death Date: #DateFormat(DeathForm.Date_Discharge_M0906,"mm/dd/yyyy")# Strengths #DeathForm.Strengths# Goals #DeathForm.Goals# Care Preference #DeathForm.Care_Preference# Risk Factor #DeathForm.Risk_Factor# Interventions #DeathForm.Interventions# Assessment Note #DeathForm.Assessment_Note# Physician Signature:______________________________________________ Transfer with Discharge Page 3

#DeathForm.First_Name_M0040# #DeathForm.Last_Name_M0040# 7 - Transferred to an inpatient facility Date Completed #DateFormat(DeathForm.Assessment_Completed_M0090,"mm/dd/yyyy")# #questions# #Evaluate(Variables.cheked_value)# - Transfer with Discharge Page #page_num#