**Interdisciplinary Care Management Form**

**Pre-admission/Pre-screening Data**

This form should be completed for new admissions or changes in patient
information. Upon completion of this form you can choose to either fax
or submit a hard copy to the appropriate location listed below:

Room# Fax \# CSA/RSA Phone \#

1NW Inpatient- 1-1655 (301) 480-3137 (301) 451-0345

1NW Day Hospital 1-2625 (301) 480-1063 (301) 451-7727

1SE (H) Peds Clinic 1-6444 (301) 480- 3714 (301) 451-9229

To ensure patient confidentiality, if you choose to fax the form, please
call the CSA/RSA of the unit, clinic or day hospital to alert them of
the pending arrival.

If the patient is to be seen in both the day hospital and clinic, please
send the form to the area the patient is to be seen on day one of the
episode of care. (An episode of care is defined as a group of
consecutive visits within one to two week period)

> **Required fields\***

**\* Pediatric Inpatient** **\* Pediatric Clinic (Select room type)**

**\* Pediatric Day Hospital** **\* Interview Room**

**\* Exam room**

**\* No preference**

**General Information: Information should be completed for each episode
of care.**

<table>
<colgroup>
<col style="width: 11%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 7%" />
<col style="width: 15%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3"><strong>*Name: Last</strong></td>
<td colspan="10"></td>
<td colspan="4"><h3 id="first">First</h3></td>
<td colspan="6"></td>
<td colspan="3"><strong>Middle</strong></td>
<td></td>
</tr>
<tr class="even">
<td colspan="6"><strong>Mailing Address (new admit or
change)</strong></td>
<td colspan="17"></td>
<td colspan="4"><strong>Gender:</strong> <strong>F</strong>
<strong>M</strong></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Contact Phone #</strong></td>
<td colspan="12"></td>
<td colspan="5"><strong>Email Address</strong></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td colspan="11"><strong>(New admit or change)</strong></td>
<td colspan="5"></td>
<td colspan="6"><strong>(New admit or change)<br />
</strong></td>
</tr>
<tr class="odd">
<td><strong>*MRN</strong></td>
<td colspan="7"></td>
<td colspan="2"><h1 id="ss">SS#</h1></td>
<td colspan="6"></td>
<td colspan="5"><strong>*DOB/Age</strong></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="2"><strong>*Protocol #</strong></td>
<td colspan="7"></td>
<td colspan="5"><strong>*Cycle/Visit #<br />
(if applicable</strong></td>
<td colspan="5"></td>
<td colspan="5"><strong>*Diagnosis</strong></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="2">*<strong>PI/Team:</strong></td>
<td colspan="13"></td>
<td colspan="5"><strong>*Fellow</strong></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="7"><strong>* Date of admission/visit:</strong></td>
<td colspan="8"></td>
<td colspan="10"><strong>* Date of discharge:</strong></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>*Person completing form:</strong></td>
<td colspan="11"></td>
<td colspan="7"><strong>Contact number:</strong></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="15" rowspan="2"><strong>*Person to be notified when patient
arrives:</strong></td>
<td colspan="7"><strong>*Phone #:</strong></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="7"><strong>*Beeper #:</strong></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="3"><strong>Date of Travel</strong></td>
<td colspan="12"></td>
<td colspan="7"><strong>Date of Departure</strong></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>Mode</strong></td>
<td colspan="2"></td>
<td colspan="7"><strong>Plane</strong></td>
<td></td>
<td colspan="6"><strong>Car</strong></td>
<td colspan="2"></td>
<td colspan="3"><strong>Other:</strong></td>
<td colspan="4"></td>
</tr>
</tbody>
</table>

+---------------+----+---+------+----+----+---+---+--------------------+
| **Name of     | *  |   |      |    |    | * |   |                    |
| Patient:**    | *L |   |      |    |    | * |   |                    |
|               | as |   |      |    |    | F |   |                    |
|               | t: |   |      |    |    | i |   |                    |
|               | ** |   |      |    |    | r |   |                    |
|               |    |   |      |    |    | s |   |                    |
|               |    |   |      |    |    | t |   |                    |
|               |    |   |      |    |    | * |   |                    |
|               |    |   |      |    |    | * |   |                    |
+---------------+----+---+------+----+----+---+---+--------------------+
| **Housing     |    | # |      | *  |    |   |   |                    |
| needed:**     |    |   |      | *N |    |   |   |                    |
|               |    | Y |      | ** |    |   |   |                    |
+---------------+----+---+------+----+----+---+---+--------------------+
| **If Yes:**   |    | * |      |    | *  |   |   |                    |
|               |    | * |      |    | *H |   |   |                    |
|               |    | C |      |    | ot |   |   |                    |
|               |    | h |      |    | el |   |   |                    |
|               |    | i |      |    | (  |   |   |                    |
|               |    | l |      |    | na |   |   |                    |
|               |    | d |      |    | me |   |   |                    |
|               |    | r |      |    | ): |   |   |                    |
|               |    | e |      |    | ** |   |   |                    |
|               |    | n |      |    |    |   |   |                    |
|               |    | ' |      |    |    |   |   |                    |
|               |    | s |      |    |    |   |   |                    |
|               |    | I |      |    |    |   |   |                    |
|               |    | n |      |    |    |   |   |                    |
|               |    | n |      |    |    |   |   |                    |
|               |    | R |      |    |    |   |   |                    |
|               |    | e |      |    |    |   |   |                    |
|               |    | f |      |    |    |   |   |                    |
|               |    | e |      |    |    |   |   |                    |
|               |    | r |      |    |    |   |   |                    |
|               |    | r |      |    |    |   |   |                    |
|               |    | a |      |    |    |   |   |                    |
|               |    | l |      |    |    |   |   |                    |
|               |    | * |      |    |    |   |   |                    |
|               |    | * |      |    |    |   |   |                    |
+---------------+----+---+------+----+----+---+---+--------------------+
| # Pe          |    |   |      |    |    |   |   |                    |
| rson accompan |    |   |      |    |    |   |   |                    |
| ying patient: |    |   |      |    |    |   |   |                    |
+---------------+----+---+------+----+----+---+---+--------------------+
| **Isolation   |    | # |      | ## |    |   |   |                    |
| needed:**     |    |   |      | ## |    |   |   |                    |
|               |    | Y |      |  N |    |   |   |                    |
+---------------+----+---+------+----+----+---+---+--------------------+

**Tests/Procedures Planned: Include date and time for each**

+---+-----------+------------------+--------+----+------+---+--------+
|   | **A       | ## Procedu       | ## Dat |    | *    |   | ## Dat |
|   | ctivity** | re / Site / Med: | e/Time |    | *Act |   | e/Time |
|   |           |                  |        |    | ivit |   |        |
|   |           |                  |        |    | y:** |   |        |
+---+-----------+------------------+--------+----+------+---+--------+
|   | **S       |                  |        |    | **Lu |   |        |
|   | edation** |                  |        |    | mbar |   |        |
|   | for:      |                  |        |    | Pu   |   |        |
|   |           |                  |        |    | nctu |   |        |
|   |           |                  |        |    | re** |   |        |
+---+-----------+------------------+--------+----+------+---+--------+
|   | **Skin    |                  |        |    | *    |   |        |
|   | Punch     |                  |        |    | *Com |   |        |
|   | Biopsy**  |                  |        |    | plex |   |        |
|   |           |                  |        |    | b    |   |        |
|   |           |                  |        |    | lood |   |        |
|   |           |                  |        |    | dr   |   |        |
|   |           |                  |        |    | aw** |   |        |
+---+-----------+------------------+--------+----+------+---+--------+
|   | *         |                  |        |    | **An |   |        |
|   | *Infusion |                  |        |    | esth |   |        |
|   | of:**     |                  |        |    | esia |   |        |
|   |           |                  |        |    | Card |   |        |
|   |           |                  |        |    | Need |   |        |
|   |           |                  |        |    | ed** |   |        |
+---+-----------+------------------+--------+----+------+---+--------+
|   | **Bone    |                  |        |    | **An |   |        |
|   | Marrow    |                  |        |    | esth |   |        |
|   | Biopsy**  |                  |        |    | esia |   |        |
|   |           |                  |        |    | Card |   |        |
|   |           |                  |        |    | Com  |   |        |
|   |           |                  |        |    | plet |   |        |
|   |           |                  |        |    | ed** |   |        |
+---+-----------+------------------+--------+----+------+---+--------+
|   | **Serial  |                  |        |    | *    |   |        |
|   | Blood     |                  |        |    | *Oth |   |        |
|   | Testing** |                  |        |    | er** |   |        |
+---+-----------+------------------+--------+----+------+---+--------+

**Special Needs:**

<table style="width:100%;">
<colgroup>
<col style="width: 6%" />
<col style="width: 10%" />
<col style="width: 14%" />
<col style="width: 30%" />
<col style="width: 7%" />
<col style="width: 8%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 8%" />
<col style="width: 1%" />
<col style="width: 6%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="3"><h2 id="patient-equipment">Patient Equipment</h2></td>
<td></td>
<td colspan="7"><strong>Dietary Needs</strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"><strong>VAD (type and size):</strong></td>
<td></td>
<td></td>
<td colspan="3"><strong>Formula</strong></td>
<td colspan="2"></td>
<td colspan="2"><strong>brand</strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"><strong>Trach (type and size):</strong></td>
<td></td>
<td></td>
<td colspan="3"><strong>Low-Fat</strong></td>
<td colspan="3"></td>
<td><strong>kcal</strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"><strong>Bi-Pap:</strong></td>
<td></td>
<td></td>
<td colspan="2"><strong>Kosher</strong></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"><strong>C-Pap:</strong></td>
<td></td>
<td></td>
<td colspan="4"><strong>Vegetarian</strong></td>
<td colspan="2"></td>
<td><strong>type</strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"><strong>G tube (type and size):</strong></td>
<td></td>
<td></td>
<td colspan="2"><strong>Diabetic</strong></td>
<td colspan="4"></td>
<td><strong>kcal</strong></td>
</tr>
<tr class="odd">
<td></td>
<td><strong>Other</strong></td>
<td colspan="2"></td>
<td></td>
<td><strong>Other</strong></td>
<td colspan="6"></td>
</tr>
</tbody>
</table>

**Assistive Devices Needed**

+---+----------------+---+---+----------------+---+------+--------------+
|   | **Seeing Eye   |   |   | **Companion    |   | #    |              |
|   | dog**          |   |   | dog**          |   |  TTY |              |
+---+----------------+---+---+----------------+---+------+--------------+
|   | **Interpreter  |   |   |                |   | #    |              |
|   | (language)**   |   |   |                |   | Inte |              |
|   |                |   |   |                |   | rpre |              |
|   |                |   |   |                |   | ter  |              |
|   |                |   |   |                |   | arra |              |
|   |                |   |   |                |   | nged |              |
+---+----------------+---+---+----------------+---+------+--------------+
|   | **Wheelchair** |   |   |                |   | #    |              |
|   |                |   |   |                |   |  Bri |              |
|   |                |   |   |                |   | ngin |              |
|   |                |   |   |                |   | g ow |              |
|   |                |   |   |                |   | n wh |              |
|   |                |   |   |                |   | eelc |              |
|   |                |   |   |                |   | hair |              |
+---+----------------+---+---+----------------+---+------+--------------+
|   | **Stroller**   |   |   |                |   | # B  |              |
|   |                |   |   |                |   | ring |              |
|   |                |   |   |                |   | ing  |              |
|   |                |   |   |                |   | own  |              |
|   |                |   |   |                |   | stro |              |
|   |                |   |   |                |   | ller |              |
+---+----------------+---+---+----------------+---+------+--------------+
|   | **Bathroom     |   | * |                |   | *    |              |
|   | Aids**         |   | * |                |   | *Oth |              |
|   |                |   | B |                |   | er** |              |
|   |                |   | e |                |   |      |              |
|   |                |   | d |                |   |      |              |
|   |                |   | a |                |   |      |              |
|   |                |   | w |                |   |      |              |
|   |                |   | a |                |   |      |              |
|   |                |   | y |                |   |      |              |
|   |                |   | f |                |   |      |              |
|   |                |   | r |                |   |      |              |
|   |                |   | o |                |   |      |              |
|   |                |   | m |                |   |      |              |
|   |                |   | w |                |   |      |              |
|   |                |   | i |                |   |      |              |
|   |                |   | n |                |   |      |              |
|   |                |   | d |                |   |      |              |
|   |                |   | o |                |   |      |              |
|   |                |   | w |                |   |      |              |
|   |                |   | * |                |   |      |              |
|   |                |   | * |                |   |      |              |
+---+----------------+---+---+----------------+---+------+--------------+

***Please attach any additional information.***