Appendix B.

TRACER skilled nursing facility visit assessment and self-reflection checklist

Skilled nursing facility assessment^
1.	Did anyone (RN or MD) call you to discuss the hospital stay and plan?
2.	Did you need to call the hospital for clarification after patient discharge?
3.	If so, with whom did you speak?
4.	Was the code status clear and accurate?
5.	Was the reason for hospitalization clear and accurate?
6.	Was the cause for chief complaint clear and accurate?
7.	Was there precipitory advice given if condition changes (i.e. if CHF and gains 2 lbs, then increase lasix dose)?
8.	Were the problems and diagnoses clear and accurate?
9.	Were the significant lab, study or diagnostic results clear and accurate?
10.	Was the medication list clear and accurate?
11.	Was the plan for tapering and/or titrating medications clear and accurate?
12.	Was the plan for non-medication therapies, such as wound care, clear and accurate?
13.	Were the lifestyle modifications (i.e. smoking cessation) clear and accurate?
14.	Was the patient education clear and accurate?
15.	Were the pending medical issues, lab results and studies clear and accurate?
16.	Were the new lab or studies to be ordered clear and accurate?
17.	Was the patient's level of function clear and accurate?
18.	Was the patient's diet tolerance and/or instruction for special feeding clear and accurate?
Skilled nursing facility reflection
1.	Did you have to solve any postdischarge problems for the patient?
2.	If yes, please list the specific problems and what you did to solve them (i.e. issues regarding medication, follow-up appointments, clarification of discharge instructions).
3.	Self-Reflection: What, if anything, will you do differently the next time you discharge a patient? (Please write 6–8 sentences for self-reflection.)

Modified from Society of Hospital Medicine Transition of Care Checklist (18).