YOUTH HEALTH INFORMATION FOR REsidential DISCHARGE
Michigan Department of Health and Human Services
Children's Services Agency
SECTION 1 – IDENTIFYING INFORMATION
Child/Youth Full Name	Date of Birth
MiSACWIS Person ID Number	Medicaid ID Number
Pronouns	Legal Status
County of Jurisdiction (Child Welfare)	County of Financial Responsibility (Mental Health)
Parent/Guardian Name	Contact Phone Number
Child/Family Worker Name	Contact Phone Number
SECTION 2 – DISCHARGE INFORMATION
Transitioning From	Agency Name	Discharge Date
Transitioning To	(Agency or Community)	Admission Date
SECTION 3 – CONTACT INFORMATION CURRENT CCI TEAM
Name	Role	Contact Phone Number
SECTION 4 – ALLERGIES
Allergy Type (Medication/food/other)	Reaction	Reported By
SECTION 5 – COVID-19 INFORMATION
Exposure/Illness	Most Recent Testing
Date	Active/Resolved	Date	Type	Result
Vaccination History
Vaccine Type	Date of First Injection	Date of Second Injection
* Note: Second injection not needed for all vaccine types

SECTION 6 – Tuberculosis (TB) INFORMATION
Most Recent Testing	Any known exposure within last year
Date	Results
SECTION 7 – IMMUNIZATION RECORD (Attach current MCIR report)
SECTION 8 – CURRENT MEDICATIONS (Attach Medication Administration Record)
SECTION 9 – Additional Medication Information
Psychotropic Medications
Medication Name	Current Prescriber
Purpose/Diagnosis
Pill Number Provided at Discharge	Prescription Provided at Discharge
Yes No
Medication Administration Directions and Monitoring Needs
Medication Name	Current Prescriber
Purpose/Diagnosis
Pill Number Provided at Discharge	Prescription Provided at Discharge
Yes No
Medication Administration Directions and Monitoring Needs
Medication Name	Current Prescriber
Purpose/Diagnosis
Pill Number Provided at Discharge	Prescription Provided at Discharge
Yes No
Medication Administration Directions and Monitoring Needs
Medication Name	Current Prescriber
Purpose/Diagnosis
Pill Number Provided at Discharge	Prescription Provided at Discharge
Yes No
Medication Administration Directions and Monitoring Needs
Medication Name	Current Prescriber
Purpose/Diagnosis
Pill Number Provided at Discharge	Prescription Provided at Discharge
Yes No
Medication Administration Directions and Monitoring Needs
Medication Name	Current Prescriber
Purpose/Diagnosis
Pill Number Provided at Discharge	Prescription Provided at Discharge
Yes No
Medication Administration Directions and Monitoring Needs
Medication Name	Current Prescriber
Purpose/Diagnosis
Pill Number Provided at Discharge	Prescription Provided at Discharge
Yes No
Medication Administration Directions and Monitoring Needs
Medication Name	Current Prescriber
Purpose/Diagnosis
Pill Number Provided at Discharge	Prescription Provided at Discharge
Yes No
Medication Administration Directions and Monitoring Needs

Medication Name	Current Prescriber
Purpose/Diagnosis
Pill Number Provided at Discharge	Prescription Provided at Discharge
Yes No
Medication Administration Directions and Monitoring Needs
Medication Name	Current Prescriber
Purpose/Diagnosis
Pill Number Provided at Discharge	Prescription Provided at Discharge
Yes No
Medication Administration Directions and Monitoring Needs
General Medications (primary care, other specialty)
Medication Name	Current Prescriber
Purpose/Diagnosis
Pill Number Provided at Discharge	Prescription Provided at Discharge
Yes No
Medication Administration Directions and Monitoring Needs
Medication Name	Current Prescriber
Purpose/Diagnosis
Pill Number Provided at Discharge	Prescription Provided at Discharge
Yes No
Medication Administration Directions and Monitoring Needs
Medication Name	Current Prescriber
Purpose/Diagnosis
Pill Number Provided at Discharge	Prescription Provided at Discharge
Yes No
Medication Administration Directions and Monitoring Needs
Medication Name	Current Prescriber
Purpose/Diagnosis
Pill Number Provided at Discharge	Prescription Provided at Discharge
Yes No
Medication Administration Directions and Monitoring Needs
Medication Name	Current Prescriber
Purpose/Diagnosis
Pill Number Provided at Discharge	Prescription Provided at Discharge
Yes No
Medication Administration Directions and Monitoring Needs
Medication Name	Current Prescriber
Purpose/Diagnosis
Pill Number Provided at Discharge	Prescription Provided at Discharge
Yes No
Medication Administration Directions and Monitoring Needs
Medication Name	Current Prescriber
Purpose/Diagnosis
Pill Number Provided at Discharge	Prescription Provided at Discharge
Yes No
Medication Administration Directions and Monitoring Needs
Medication Name	Current Prescriber
Purpose/Diagnosis
Pill Number Provided at Discharge	Prescription Provided at Discharge
Yes No
Medication Administration Directions and Monitoring Needs
Medication Name	Current Prescriber
Purpose/Diagnosis
Pill Number Provided at Discharge	Prescription Provided at Discharge
Yes No
Medication Administration Directions and Monitoring Needs
Medication Name	Current Prescriber
Purpose/Diagnosis
Pill Number Provided at Discharge	Prescription Provided at Discharge
Yes No
Medication Administration Directions and Monitoring Needs
SECTION 10 – HEALTH PROBLEMS AND FOLLOW UP INFORMATION
Diagnosis (ICD/Name)	Follow Up Information

SECTION 11 - SIGNATURES
Staff completing the form (if not nursing)
Name	Signature	Date
Notes
Nursing Review: I reviewed this information and attest it is either correct as is, or I have amended as in the notes section below.
Name	Signature	Date
Notes
SECTION 12 - Acknowledgment of Receipt of Discharge Health Information
Name	Signature	Date
Notes

NOTES	This form is used by residential providers to document health information about the youth at the time of discharge. This information will be used to support the next caregiver team in achieving continuity of health and mental health care after discharge.
INSTRUCTIONS (items not listed are self-explanatory)
GENERAL	Date of Birth should be entered in the following format: MM/DD/YYYY. Telephone contact information should be entered in the following format: XXX-XXX-XXXX.
SECTION 1	Child Welfare County of Jurisdiction refers to the county that has responsibility for managing the child welfare case whether the child and family is working directly with the county DHHS or a private agency. This may or may not be the county where the child is residing. Mental Health County of Financial Responsibility is usually the county where the child was last residing in a community-based placement. If a child residing in a QRTP or non-QRTP CCI needs to be evaluated for psychiatric admission, the County of Financial Responsibility would take the lead in conducting that evaluation. When a child is being discharged from a QRTP or non-QRTP CCI to a community setting, the County of Financial Responsibility will be the county where the child will be residing after discharge and the team with whom the QRTP and child welfare would collaborate on aftercare planning.
SECTION 3	Contacts should include all members if the health care team who have been working with the youth during QRTP/non-QRTP CCI admission, including providers on and off site.
SECTION 4	Review the youth’s health records and document allergy information in this section.
SECTION 5	Review the youth’s health records and update any COVID-19 information since admission.
SECTION 6	Review the youth’s health records and update any tuberculosis information since admission.
SECTION 7	Print the current Michigan Care Improvement Registry (MCIR) report and attach to this form.
SECTION 8	Print your organization’s Medication Administration Record for the youth as of the date of discharge and attach to this form.
SECTION 9	Note that the Medication Administration Record (MAR) from Section 8 will contain the name and administration directions for each medication. This section should be used for additional information that will be important to the next caregiver team. For each medication, re-enter the medication name as listed in the MAR, enter the current prescriber, the purpose or diagnosis (reason) the medication is used, the pill number, if any are provided (note that this field can also be used if the medication is in a different form, like a liquid or an inhaler) and whether an additional prescription for that medication is provided at discharge. Medication Administration Directions should include any additional specific directions not included on the MAR that will help the youth and team continue the medication, for example if the youth does better if they eat before taking the medication or if they need to take the medication on an empty stomach. Medication Monitoring Needs includes specific ongoing monitoring needed. For example, when taking some medications, regular laboratory work is needed. For a youth taking clozapine (Clozaril) very specific laboratory monitoring must be done for the pharmacy to continue filling this medication. Please note that it may be good to attach medication information sheets if you have them. If you need more spaces for medications, please print an additional page 2 and continue entry.
SECTION 10	This section should include information about any ongoing non-medication treatment or other follow up for each of the youth’s health needs. For example, if they work with a provider for a diagnosis of seizure disorder, provide the next time they will need a follow up appointment and how to arrange for that appointment. If the youth will need to arrange to see a provider other than the one they may have been working with during their time in the facility, please provide some information about how to arrange, for example suggesting that they contact their insurance care management team.
SECTION 11	If this discharge form is completed by facility staff other than a nurse, that person should print their name, sign and date and put in any notes that the nurse should attend to prior to discharge. The facility nurse should review all the information on the form (if completed by another staff person), print, sign and date the form and put in any additional notes that the next team will need. Note that when a youth transitions from one QRTP/non-QRTP CCI to another the nurses from the referring and receiving program must have a transition of care call where the information on this form is discussed.
SECTION 12	Review the information on this form with the person accompanying the youth at the time they are discharged (child and family worker, parent, foster caregiver, transporter). Their name, signature and date will verify that they heard the information and got a copy of the document and medication supply.
ROUTING	Once this form has been completed, reviewed by nursing, and health information issues have been resolved, the form should be reviewed and signed as noted in Section 12, provided to the person accompanying the youth and a copy sent to the child and family/JJ worker so that MiSACWIS can be updated. The discharging facility can retain a copy for their records.
The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, gender identification or expression, sexual orientation, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.