Form DCF-2271 "Congregate Care Discharge Summary" - Connecticut

What Is Form DCF-2271?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2018;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DCF-2271 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-2271 "Congregate Care Discharge Summary" - Connecticut

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Connecticut Department of Children and Families
CONGREGATE CARE DISCHARGE SUMMARY
DCF-2271
4/18 (Rev)
Page 1 of 4
Last Name:
First Name:
DOB:
Age:
Gender:
Select One or enter your own
LINK#:
Allergies:
Dates of Stay:
Medical Diagnosis:
Behavioral Health Diagnosis:
Past medical History
Connecticut Department of Children and Families
CONGREGATE CARE DISCHARGE SUMMARY
DCF-2271
4/18 (Rev)
Page 1 of 4
Last Name:
First Name:
DOB:
Age:
Gender:
Select One or enter your own
LINK#:
Allergies:
Dates of Stay:
Medical Diagnosis:
Behavioral Health Diagnosis:
Past medical History
DCF-2271 CONGREGATE CARE DISCHARGE SUMMARY
Page 2 of 4
Last Name:
First Name:
DOB:
Dates of Stay:
Current Medications: (Drug/Dose/Route/Time/Last Dose/Target Symptoms). If applicable, please put date of last CMCU consent obtained:
Medication Changes: (Date/Drug//Dose/Routs/Time/Reason, Adverse Reaction, No Effect)
PROCEDURES / SURGERY / HOSPITALIZATION
Name of Primary Care Doctor or Specialist
E-mail:
Telephone:
Address:
City:
State:
Zip:
Connecticut
Date of last Visit / Reason / Outcome / .Follow-up Appointment:
Other Specialists: (include name, address, date of last visit and follow-up appointments):
DCF-2271 CONGREGATE CARE DISCHARGE SUMMARY
Page 3 of 4
Last Name:
First Name:
DOB:
Dates of Stay:
Name of Psychiatrist
E-mail:
Telephone:
Address:
City:
State:
Zip:
Connecticut
Date of last Appointment / Reason / Outcome / .Follow-up Appointment:
Name of Dentist
E-mail:
Telephone:
Address:
City:
State:
Zip:
Connecticut
Date of last Dental Exam / Reason / Outcome / .Follow-up Appointment:
Name of Eye Doctor:
E-mail:
Telephone:
Address:
City:
State:
Zip:
Connecticut
Date of last Vision Exam /.Follow-up Appointment:
IMMUNIZATION:
AIMS
EKG
LABS
Current
Date:
Date:
Date:
Needs (Please list below):
Results:
Results
Results:
NUTRITION:
EXERCISE:
ADAPTIVE EQUIPMENT:
Regular
Unrestricted
None
Adjustment (Please list below):
Recommended (Please list below):
Type of Equipment Needed (Please let below):
Height:
Weight:
BMI/BMI %
BP:
P:
R:
Pain Scale: (0-10)
DCF-2271 CONGREGATE CARE DISCHARGE SUMMARY
Page 4 of 4
Last Name:
First Name:
DOB:
Dates of Stay:
Nursing Summary:
DISCHARGE ACTIONS: Are the Documents Attached?
Yes
No
Recent Physical:
Immunization Record:
EKG / LAB Work:
AIMS:
FORM 465
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
PROVIDED
Yes
No Medications (Including Inhalers and Epi Pens)
Yes
No Print Discharge Medication List (If applicable)
Yes
No Prescriptions (If ‘Yes”, please list):
Was Education provided to parent or guardian during this quarter? Yes
No
.
If “yes” please provide details:
Comments:
Name of RN Completing Assessment
Signature of RN
Date
Page of 4