Skilled Nursing Facility Admission Pre-Screen

Skilled Nursing Facility Admission Pre-Screen — Form Fields

This healthcare template includes 13 fields. SNF admissions coordinators complete a pre-screening for patients transferring from an acute care setting. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Sending Facility (text, required)
• Sending Case Manager (text, required)
• Case Manager Email (email, required)
• Primary Diagnosis (dropdown selection, required) — options: Hip Fracture, Stroke, CHF Exacerbation, Pneumonia, COPD, Sepsis, Post-Surgical Recovery, Other
• Functional Status (dropdown selection, required) — options: Independent, Supervision Required, Partial Assistance, Total Assist
• Weight Bearing Status (dropdown selection, required) — options: Full, Partial, Non-Weight Bearing, Toe-Touch Only
• Requires IV Antibiotics? (dropdown selection, required) — options: Yes, No
• Requires Wound Care? (dropdown selection, required) — options: Yes, No
• Behavioral or Cognitive Concerns? (dropdown selection, required) — options: None, Mild Dementia, Moderate Dementia, Behavioral Issues
• Insurance (dropdown selection, required) — options: Medicare A, Medicare Advantage, Medicaid, Private Pay, Other
• Other clinical considerations (long text, optional)