ࡱ> eh`abcd bjbj 7hhؾH H 8 pn(999::>\@lllllllxqtl!A::AAl9:ogOgOgOAX9:lgOAlgOgOek9R!Bjlo0 pwkt!B t ktkHA\AgOjA vASHAHAHAllKHAHAHA pAAAAtHAHAHAHAHAHAHAHAHAH Q: DEMOGRAPHIC INFORMATION Note to Assessor: Each of the fill-in boxes within this form must be completed. If an item is not applicable, note this by entering n/a in the fill-in box. Blank responses will be considered incomplete and may result in this form being placed in pending statusresulting in processing delays. Client Information Street Address:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT       Zip Code:  FORMTEXT       Home Phone:  FORMTEXT       Work Phone:  FORMTEXT       Cell Phone:  FORMTEXT       Date of Birth:  FORMTEXT       Current Age:  FORMTEXT       Medicaid #:  FORMTEXT       Medicare #:  FORMTEXT       Veteran #:  FORMTEXT       Other Insurance:  FORMTEXT       Present Location  FORMCHECKBOX  Same As Above Facility:  FORMTEXT       Street Address:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT       Zip Code:  FORMTEXT       Phone:  FORMTEXT      Demographic Data Race:  FORMTEXT       Primary Language:  FORMTEXT       Gender:  FORMTEXT       Marital Status:  FORMTEXT       Education:  FORMTEXT       Living Arrangements:  FORMTEXT       Total In Home:  FORMTEXT       If client does not live alone, indicate number of persons under each category: Client s Spouse:  FORMTEXT       Client s Parent(s):  FORMTEXT       Client s Siblings:  FORMTEXT       Children (under age 18, regardless of parentage):  FORMTEXT       Adult Children:  FORMTEXT       Other Relatives:  FORMTEXT       Others (ex: friends, roommates):  FORMTEXT      General Information:  FORMTEXT       SECTION A: Professional Nursing Services Use the following codes for section A. 1-A.10 (every block should be coded with a response). Personnel will need care that is or otherwise would be performed by or under the supervision of a registered professional nurse. Condition/treatment not present in the last 7days 1-2 days a week 3-4 days a week 5-6 days a week 7 days a week Once a month At least once every 8 hours/7 days a week (used for Extended PDN only) Twice a month 1. Injections/IV Feeding Injections/IV feeding for an unstable condition (excluding daily insulin for a person whose diabetes is under control): a. Intraarterial injection  FORMDROPDOWN  b. Intramuscular injection  FORMDROPDOWN  Subcutaneous injection  FORMDROPDOWN  d. Intravenous injection  FORMDROPDOWN  Intravenous feeding (Parenteral or IV feeding.)  FORMDROPDOWN  2. Feeding Tube Feeding tube for a new/recent (within 30 days) or an unstable condition: Insertion date:  FORMTEXT       Nasogastric tube  FORMDROPDOWN  Gastrostomy tube  FORMDROPDOWN  Jejunostomy tube  FORMDROPDOWN  3. Suctioning/Trach Care Nasopharyngeal suctioning  FORMDROPDOWN  Tracheostomy care for a new/recent (within 30 days) or an unstable condition  FORMDROPDOWN  Start date:  FORMTEXT       4. Treatment/Dressings Treatment and/or application of dressings for one of the following conditions for which the physician has prescribed irrigation, application of medications, or sterile dressings and which requires the skill of an RN: a. Stage 3 or 4 decubitus ulcers  FORMDROPDOWN  b. Open surgical site  FORMDROPDOWN  c. 2nd or 3rd degree burns  FORMDROPDOWN  Stasis ulcer  FORMDROPDOWN  Open lesions other than stasis/pressure ulcers or cuts (including but not limited to fistulas, tube sites and tumor erosions)  FORMDROPDOWN  Other/Explain: FORMTEXT       5. Oxygen Administration of oxygen on a regular and continuing basis when recipient s condition warrants professional observation for a new/recent (within 30 days) condition. Start date:  FORMTEXT        FORMDROPDOWN  6. Assessment/Management Professional nursing assessment, observation and management required for unstable medical conditions. Observation must be needed at least once every 8 hours. Specify condition and code for applicants need Please specify:  FORMTEXT        FORMDROPDOWN  7. Catheter Insertion and maintenance of a urethral or suprapubic catheter as an adjunct to a disease or a medical condition  FORMDROPDOWN  8. Comatose Professional care is needed to manage a comatose condition.  FORMDROPDOWN  9. Ventilator/Respirator Care is needed to manage ventilator/respirator equipment.  FORMDROPDOWN  10. Uncontrolled Seizure Disorder Direct assistance from others is needed for safe management of an uncontrolled seizure disorder.  FORMDROPDOWN  11. Therapy-Therapies provided by a qualified therapist. (Indicate the number of days per week for each therapy required. Enter 0 if none.) Days per Week a. Physical therapy ___  FORMDROPDOWN _____ b. Speech/language therapy ___ FORMDROPDOWN _____ c. Occupational therapy ___ FORMDROPDOWN _____ d. Respiratory therapy ___ FORMDROPDOWN _____ Total # of days of therapy per week  FORMTEXT       Therapy- Is therapy required a least once a month for any of the following: physical, speech/language, occupational or respiratory therapy? 0  No 1  Yes  FORMDROPDOWN  13. Assessment/Management Professional nursing assessment, observation and management of a medical conditions once a month. Specify condition and code for applicant s need. Please specify:  FORMTEXT       0  No 1  Yes  FORMDROPDOWN  SECTION B: Special Treatments and Therapies 1. Treatments-Chronic Conditions Code for number of days care would be performed by or under the supervision of a registered nurse. Not required 1-2 days/week 2. 3 or more day/week Once a month 7. Twice a month2. Treatments/Procedures Code for number of days professional nursing is required. a. Chemotherapy  FORMDROPDOWN  b. Radiation Therapy  FORMDROPDOWN  g. Hemodialysis  FORMDROPDOWN  h. Peritoneal Dialysis  FORMDROPDOWN  Professional nursing care and monitoring for administration of treatments, procedures, or dressing changes which involve prescription medications, for post-operative or chronic conditions according to physician orders. a. Medications via tube  FORMDROPDOWN  b. Tracheostomy care-chronic stable  FORMDROPDOWN  Urinary catheter change  FORMDROPDOWN  Urinary catheter irrigation  FORMDROPDOWN  Veni puncture by RN  FORMDROPDOWN   f. Monthly injections  FORMDROPDOWN  g. Barrier dressings for Stage 1 or 2 ulcers  FORMDROPDOWN  h. Chest PT by RN  FORMDROPDOWN  i. O2 therapy by RN for chronic unstable condition  FORMDROPDOWN  j. Other, specify:  FORMTEXT        FORMDROPDOWN  k. Teach/Train  FORMDROPDOWN  SECTION C: Cognition 1. Memory (Recall of what was learned or known) 0  Memory OK 1  Memory problems Short-term memory  seems/appears to recall after 5 minutes  FORMDROPDOWN  Long term memory seems/appears to call long past  FORMDROPDOWN  Memory/Recall Ability (Check all that person normally able to recall during last 7 days; 24 48 hrs, if in hospital) Current season  FORMCHECKBOX  Location of own room  FORMCHECKBOX  Names/faces  FORMCHECKBOX  Where he/she is  FORMCHECKBOX  None of the above were recalled  FORMCHECKBOX 3. Cognitive Skills for Daily Decision-Making - Made decisions regarding tasks of daily life. Independent decisions consistent/reasonable Modified independence some difficulty in new situations only Moderately impaired decisions poor, cues/ supervision required Severely impaired never/rarely made decisions  FORMDROPDOWN  4A. Is professional nursing assessment, observation and management required at least 3 days/week to manage all the above cognitive patterns? 0 No 1 Yes  FORMDROPDOWN  If 4A = 1 (Yes), proceed to 5. If 4A = 0 (No) and person meets the cognitive impairment threshold, then go to Section C.4B of the Supplemental Screening Tool. 5. Is professional nursing assessment, observation and management required once a month to manage all the above cognitive patterns? 0 No 1 Yes  FORMDROPDOWN  SECTION D: Problem Behavior Column A Codes: Code for the frequency of behavior in last 7 days Behavior not exhibited in last 7 days Behavior of this type occurred 1 to 3 days in last 7 days Behavior of this type occurred 4 to 6 days, but less than daily Behavior of this type occurred daily Column B Codes: Alterability of behavior symptoms Not present or easily altered Behavior not easily altered a. Wandering (moved with no rational purpose, seemingly oblivious to needs or safety) A FORMDROPDOWN  B FORMDROPDOWN  b Verbally Abusive (others threatened, screamed at, cursed at) A FORMDROPDOWN  B FORMDROPDOWN  Physically Abusive (others were hit, shoved, scratched, sexually abused) A FORMDROPDOWN  B FORMDROPDOWN  d. Socially Inappropriate/Disruptive Behavior (made disruptive sounds, noisy, screams, self-abusive acts, sexual behavior or disrobing in public, smeared/threw food/feces, hoarding, rummaged through others belongings) A FORMDROPDOWN  B FORMDROPDOWN  e. Resists Care (resisted taking medications/injections, ADL assistance or eating) A FORMDROPDOWN  B FORMDROPDOWN  2a. Is professional nursing assessment, observation and management required at least 3 days/week to manage the behavior problems items a-d? 0 No 1 Yes  FORMDROPDOWN  If 2a = 1 (Yes) proceed to 3. If 2A = 0 (No) and person meets the behavioral impairment threshold, then go to page 3A and complete Section D.2B of the Supplemental Screening Tool. 3. Is professional nursing assessment, observation and management required once a month to manage the above behavior problems? 0 No 1 Yes  FORMDROPDOWN SECTION E: Physical Functioning/Structural Problems 1. ADL Self-Performance (Code for Performance during last 7 days (24 48 hrs if in hospital) not including setup.) Independent No help or oversight or Help/oversight provided only 1 or 2 times during last 7 days. Supervision Oversight, encouragement or cueing provided 3 + times during last 7 days OR Supervision plus nonweight-bearing physical assistance provided only 1 or 2 times during last 7 days. Limited Assistance Person highly involved in activity; received physical help in guided maneuvering of limbs, or other nonweight-bearing assistance 3+ times OR Limited assistance (as just described) plus weight-bearing 1 or 2 times during the last 7 days. Extensive Assistance While person performed part of activity, over last 7-day period, help of following types(s) provided 3 or more times: -Weight-bearing support -Full staff/caregiver performance during part (but not all) of last 7 days. Total Dependence Full staff/caregiver performance of activity during ENTIRE 7 days. Cueing Spoken instruction or physical guidance which serves as a signal to do an activity are required 7 days a week. Cueing is typically used when caring for individuals who are cognitively impaired. ACTIVITY DID NOT OCCUR during entire 7 days. ADL Support Provided - (Code for Most Support Provided Over Each 24 Hour Period during last 7 days (24-48 hours if person is in hospital); code regardless of persons self-performance classification.) No setup or physical help from staff Setup help only One-person physical assist Two+ persons physical assist 5. Cueing- Cueing support required 7 days a week Activity did not occur during entire 7 days Self-Performance Bed Mobility (How person moves to and from lying position, turns side to side, and positions body while in bed) A  FORMDROPDOWN  B  FORMDROPDOWN  Transfer (How person moves between surfaces to/from bed, chair, wheelchair, standing position (Exclude to/from bath/toilet) A  FORMDROPDOWN  B  FORMDROPDOWN  Locomotion (How person moves between locations in his/her room and other areas on same floor. If in wheelchair, self-sufficiency once in chair ) A  FORMDROPDOWN  B  FORMDROPDOWN  Dressing ( How person puts on, fastens, and takes off all items of street clothing, including donning/removing prosthesis) A  FORMDROPDOWN  B  FORMDROPDOWN  Eating (How person eats and drinks regardless of skill) A  FORMDROPDOWN  B  FORMDROPDOWN  Toilet Use (How persons uses the toilet room (or commode, bedpan, urinal); transfers on/off toilet, cleanses, changes pad, manages ostomy or catheter, adjusts clothes) A  FORMDROPDOWN  B  FORMDROPDOWN  g. Personal Hygiene (How person maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face, hands, and perineum (Exclude baths and showers) A  FORMDROPDOWN  B  FORMDROPDOWN  Walking How person walks for exercise only A  FORMDROPDOWN  B  FORMDROPDOWN  How person walks around own room A  FORMDROPDOWN  B  FORMDROPDOWN  How person walks within home A  FORMDROPDOWN  B  FORMDROPDOWN  How person walks outside A  FORMDROPDOWN  B  FORMDROPDOWN  Bathing (How person takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (Exclude washing of back and hair). (Code for most dependent in self performance and support. Bathing Self-Performance codes appear below.) Independent No help provided A  FORMDROPDOWN  B  FORMDROPDOWN  Supervision Oversight help only A  FORMDROPDOWN  B  FORMDROPDOWN  Physical help limited to transfer only A  FORMDROPDOWN  B  FORMDROPDOWN  Physical help in part of bathing activity A  FORMDROPDOWN  B  FORMDROPDOWN  Total dependence A  FORMDROPDOWN  B  FORMDROPDOWN  Cueing Cueing support required 7 days a week A  FORMDROPDOWN  B  FORMDROPDOWN  Activity did not occur during entire 7 days. A  FORMDROPDOWN  B  FORMDROPDOWN   SECTION C4B: COGNITION (Enter the code that most accurately describes the persons cognition for the last 7 days) 1. Memory For Events:  FORMDROPDOWN  Can recall details and sequences of recent experiences and remember names of meaningful acquaintances. Cannot recall details or sequences of recent events or remember names of meaningful acquaintances. Cannot recall entire events (e.g. recent outings, visits of relatives or friends) or names of close friends or relatives without prompting. Cannot recall entire events or name of spouse or other living partner even with prompting. 2. Memory And Use Of Information:  FORMDROPDOWN  Does not have difficulty remembering and using information. Does not require directions or reminding from others. Has minimal difficulty remembering and using information. Requires direction and reminding from others one to three times per day. Can follow simple written instructions. 3. Has difficulty remembering and using information. Requires direction and reminding from others four or more times per day. Cannot follow written instructions. 4. Cannot remember or use information. Requires continual verbal reminding. ________________________________________________________________ 3. Global Confusion: . FORMDROPDOWN  Appropriately responsive to environment. Nocturnal confusion on awakening. Periodic confusion during daytime. Nearly always confused. 4. Spatial Orientation:  FORMDROPDOWN  Oriented, able to find and keep his/her bearings. Spatial confusion when driving or riding in local community. Gets lost when walking neighborhood. Gets lost in own home or present environment. 5. Verbal Communication:  FORMDROPDOWN  Speaks normally. Minor difficulty with speech or word-finding difficulties. Able to carry out only simple conversations. 3. Unable to speak coherently or make needs known. C.4B Total Cognitive Score  FORMTEXT       SECTION D.2B: BEHAVIOR Enter the code that most accurately describes the person s behavior for the last 7 days. Sleep Patterns:  FORMDROPDOWN  Unchanged from  normal for the consumer. Sleeps noticeably more or less than  normal. 3. Restless, nightmares, disturbed sleep, increased awakenings. 4. Up wandering for all or most of the night, inability to sleep. 2. Wandering:  FORMDROPDOWN  Does not wander. Does not wander. Is chair bound or bed bound. Wanders within the facility or residence and may wander outside, but does not jeopardize health and safety. Wanders within the facility or residence. May wander outside, health and safety may be jeopardized. Does not have history of getting lost and is not combative about returning. Wanders outside and leaves grounds. Has consistent history of leaving grounds, getting lost or being combative about returning. Requires a treatment plan that may include the use of psychotropic drugs for management and safety. 3. Behavioral Demands On Others:  FORMDROPDOWN  0. Attitudes, habits and emotional states do not limit the individuals type of living arrangement and companions. 1. Attitudes, habits and emotional states limit the individuals type of living arrangement and companions. 3. Attitudes, disturbances and emotional states create consistent difficulties that are modifiable to manageable levels. The consumers behavior can be changed to reach the desired outcome through respite, in-home services, or exiting facility staffing. 4. Attitudes, disturbances and emotional states create consistent difficulties that are not modifiable to manageable levels. The consumers behavior cannot be changed to reach the desired outcome through respite, in-home services, or existing facility staffing even given training for the caregiver. 4. Danger To Self And Others:  FORMDROPDOWN  Is not disruptive or aggressive, and is not dangerous. Is not capable of harming self or others because of mobility limitations (is bed bound or chair bound). Is sometimes (1 to 3 times in the last 7 days) disruptive or aggressive, either physically or verbally, or is sometimes extremely agitated or anxious, even after proper evaluation and treatment. Is frequently (4 or more time during the last 7 days) disruptive or aggressive, or is frequently extremely agitated or anxious; and professional judgment is required to determine when to administer prescribed medication. 5. Is dangerous or physically abusive, and even with proper evaluation and treatment may require physicians orders for appropriate intervention. 5. Awareness of Needs/Judgment:  FORMDROPDOWN  Understands those needs that must be met to maintain self care. Sometimes (1 to 3 times in the last 7 days) has difficulty understanding those needs that must be met but will cooperate when given direction or explanation. Frequently (4 or more time during the last 7 days) has difficulty understanding those needs that must be met but will cooperate when given direction or explanation. Does not understand those needs that must be met for self care and will not cooperate even though given direction or explanation. D.2B total Behavior Score  FORMTEXT       Return to Section D3  SECTION F: Medications List List all medications given during the last 7 days. Include medications used regularly less than weekly as part of the person s treatment regimen.1. List the medication name and the dosage RA (Route of Administration). Use the appropriate code from the following list1 = by mouth (PO) 2 = sublingual (SL)3 = intramuscular (M) 4 = intravenous (IV)5 = subcutaneous (SubQ) 6 = rectally7 = topical 8 = inhalation 9 = enternal tubeFREQ (Frequency): Use the appropriate frequency code to show the number of times per day that the meditation was given.PR=(PRN) as necessary 1H=(qh) every hour 2H=(q2h) every 2 hours 3H=(q3h) every 3 hours 4H=(qrh) every 4 hours6H=(q6h) every 6 hours 8H=(q8h) every 8 hours 1D=(qd or hs) once daily 2D=BID 2 times daily, (includes every 12 hours)3D=(TID) 3 times daily 4D=(QID) 4 times daily 5D= 5 times daily 1W=(Q week) once every week 2W=twice every week3W=3 times every week QO=every other day 4W=4 times every week 5W=5 times every week 6W=6 times every week1M=(Qmonth) once every month 2M=twice every month C-continuous O= otherPRN-n (prn-number of doses): If the frequency code is PR, record the number of times during the past 7 days that each PRN medication was given. Do not use this column for scheduled medications.OTC DrugsMedication Name and Dosage2. RA3. Freq4. PRNExample: Coumadin 2.5 mg Humulin R 25 Units Robitussin 15 cc1 5 11W 1D PR 2 FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN Continue to list medications in spaces provided following Section R if necessary.SECTION G: Medication 1a. Preparation / Administration Did person prepare and administer his/her own medications In the last 7 days?  FORMDROPDOWN  Person prepared and administered ALL of his/her own medications. Person prepared and administered SOME of his/her own medications. Person prepared and administered NONE of his/her own medications. Person had no medications in the last 7 days. Person did not prepare but did self-administer all medications. Facility prepares and administers medications. 6. Person requires administration of medications due to severe and disabling illness. 1b. Compliance Persons level of compliance with medications prescribed by a physician/psychiatrist in the last 7 days  FORMDROPDOWN  Person always compliant. Person compliant some of the time (80% of time or more often) OR compliant with some medications. Person rarely or never compliant. Person had no medications during last 7 days. Person requires monitoring of medications due to severe and disabling illness. 1c. Self-Administration Did person self-administer any of the following meditations or treatments in the last 7 days?  FORMCHECKBOX  a. Insulin FORMCHECKBOX  b. Oxygen FORMCHECKBOX  c. Nebulizers FORMCHECKBOX  d. Nitropatch  FORMCHECKBOX  e. Glucoscan FORMCHECKBOX  f. OTC Medsg.  FORMCHECKBOX  Other Specify  FORMTEXT       FORMCHECKBOX  h. None SECTION H: Diagnoses Diagnoses: Check only those diagnoses that have a relationship to current ADL status, cognitive status, mood and behavior status, medical treatments, nurse monitoring, or risk of death. (Do not list inactive diagnoses.) If none apply, check xx, None of the Above.ENDOCRINE/METABOLIC/ NUTRITIONAL  FORMCHECKBOX  a. Diabetes mellitus  FORMCHECKBOX  b. Hyperthyroidism  FORMCHECKBOX  c. Hypothyroidism HEART/CIRCULATION  FORMCHECKBOX  d. Arteriosclerotic heart disease-ASHD  FORMCHECKBOX  e. Cardiac dysrhythmia  FORMCHECKBOX  f. Congestive heart failure  FORMCHECKBOX  g. Deep vein thrombosis  FORMCHECKBOX  h. Hypertension  FORMCHECKBOX  i. Hypotension  FORMCHECKBOX  j. Peripheral vascular disease  FORMCHECKBOX  k. Other cardiovascular disease MUSCULOSKELETAL  FORMCHECKBOX  l. Arthritis  FORMCHECKBOX  m. Hip fracture  FORMCHECKBOX  n. Missing limb(e.g. amputation)  FORMCHECKBOX  o. Osteoporosis  FORMCHECKBOX  p. Pathological bone fracture NEUROLOGICAL  FORMCHECKBOX  q. Alzheimers disease  FORMCHECKBOX  r. Aphasia  FORMCHECKBOX  s. Cerebral palsy  FORMCHECKBOX  t. Cerebrovascular accident (stroke)  FORMCHECKBOX  u. Dementia other than Alzheimers  FORMCHECKBOX  v. Hemiplegia / hemiparesis  FORMCHECKBOX  w. Multiple sclerosis  FORMCHECKBOX  x. Paraplegia  FORMCHECKBOX  y. Parkinsons disease  FORMCHECKBOX  z. Quadriplegia  FORMCHECKBOX  aa. Seizure disorder  FORMCHECKBOX  bb. Transient ischemic attack (TIA)  FORMCHECKBOX  cc. Traumatic brain injury PSYCHIATRIC/MOOD  FORMCHECKBOX  dd. Anxiety disorder  FORMCHECKBOX  ee. Depression  FORMCHECKBOX  ff. Manic Depression (Bipolar Disease)  FORMCHECKBOX  gg. Schizophrenia PULMONARY  FORMCHECKBOX  hh. Asthma  FORMCHECKBOX  ii. Emphysema / COPD  FORMCHECKBOX  ii.a. Bronchitis  FORMCHECKBOX  ii.b. Pneumonia SENSORY  FORMCHECKBOX  jj. Cataracts  FORMCHECKBOX  kk. Diabetic retinopathy  FORMCHECKBOX  ll. Glaucoma  FORMCHECKBOX  mm. Macular degeneration OTHER  FORMCHECKBOX  nn. Allergies (specify)  FORMTEXT        FORMCHECKBOX  oo. Anemia  FORMCHECKBOX  pp. Cancer  FORMCHECKBOX  qq. Renal failure  FORMCHECKBOX  rr. Tuberculosis  FORMCHECKBOX  ss. HIV  FORMCHECKBOX  tt. Mental retardation(e.g., Down s syndrome, autism, or other condition related to MR or DD  FORMCHECKBOX  uu. Substance abuse (alcohol or drug)  FORMCHECKBOX  vv. Other psychiatric diagnosis, (e.g. paranoia, phobias, personality disorder)  FORMCHECKBOX  ww. Explicit terminal prognosis  FORMCHECKBOX  xx. None of the Above2.Other Current DX. & ICD-9 Codes a.  FORMTEXT        FORMTEXT       b.  FORMTEXT        FORMTEXT       c.  FORMTEXT        FORMTEXT      3. 2 or more hospitalizations r/t primary / secondary diagnosis FORMCHECKBOX  3a. NF placement in the past 12 months r/t primary / secondary diagnosis  FORMCHECKBOX  3b. 5 or more ER visits r/t primary / secondary diagnosis  FORMCHECKBOX SECTION I: Communication/ Hearing Patterns Hearing (Choose only one) (With hearing appliance, if used) Hears adequately-normal talk, TV, phone Minimal Difficulty when not in quiet setting Hears in Special Situations only-speaker has to adjust tonal quality and speak distinctly Highly Impaired absence of useful hearing  FORMDROPDOWN  Communication Devices/Techniques (Check all that apply during last 7 days)  FORMCHECKBOX  a. Hearing aid, present and used  FORMCHECKBOX  b. Hearing aid, present and not used regularly  FORMCHECKBOX  c. Other receptive communication techniques used (e.g., lip reading)  FORMCHECKBOX  d. None of the Above Making Self Understood (Expressing information content-however able) (Choose only one) Understood Usually understood-difficulty finding words or finishing thoughts Sometimes understood-ability is limited to making concrete requests Rarely/Never understood  FORMDROPDOWN  Ability to Understand Others (Understanding information content-however able) (Choose only one) Understands Usually understands-may miss some part/intent of message Sometimes understands-responds adequately to simple, direct communication Rarely/Never understands  FORMDROPDOWN SECTION J. Vision Patterns 1. Vision (Ability to see in adequate light & with glasses if used) Adequate - sees fine detail, including regular print in newspapers/books Impaired - sees large print, but not regular print in newspapers/books Moderately impaired - limited vision; not able to see newspaper headlines, but can identify objects. Highly impaired - object identification in question, but eyes appear to follow objects. Severely impaired - no vision or sees only light, colors, or shapes; eyes do not appear to follow objects.  FORMDROPDOWN  2. Visual appliances a. Glasses, contact lenses 0 No 1 Yes  FORMDROPDOWN  b. Artificial eye 0 No 1 Yes  FORMDROPDOWN  SECTION K: Nutritional Status Weight (optional if info is not available.) Record weight in pounds. Base weight on most recent measure in last 30 days; measure weight consistently in accord with standard practice (e.g., in a.m. after voiding, before meal, with shoes off, and in nightclothes) WT  FORMTEXT       Weight Change (optional if info is not available.) No weight change  FORMTEXT       Unintended weight gain* (*5% or more in last 30 days; or _____ Unintended weight loss * 10% or more in last 180 days) ____ Nutritional Problems or Approaches (check all that apply) FORMCHECKBOX  a. Chewing or swallowing  FORMCHECKBOX  b. Complains about the taste of many foods  FORMCHECKBOX  c. Regular or repetitive complaints of hunger  FORMCHECKBOX  d. Leaves 25% or more of food un- eaten at most meals  FORMCHECKBOX  e. Therapeutic diet FORMCHECKBOX  f. Mechanically altered (or pureed) diet.  FORMCHECKBOX  g. Noncompliance with diet  FORMCHECKBOX  h. Food Allergies/ specify:  FORMTEXT        FORMCHECKBOX  i. Restrictions/ specify:  FORMTEXT        FORMCHECKBOX  j. None of the Above SECTION L: Continence in Last 14 Days Bladder Continence (Choose only one.) Control of urinary bladder function (if dribbles, volume insufficient to soak through underpants) with appliances if used (e.g., pads or incontinence program employed) in last 14 days. Continent-complete control  FORMTEXT       Usually Continent- incontinent episodes once a week or less Occasionally incontinent-2 or more times a week but not daily Frequently incontinent-tended to be incontinent daily, some control present Incontinent-bladder incontinent all (or almost all) of the time Bowel Continence (Choose only one) Continent - complete control  FORMTEXT       Usually Continent - Bowel incontinent episodes less than weekly Occasionally incontinent - bowel incontinent episode once a week Frequently incontinent bowel incontinent episodes 2 to 3 times per week 4. Incontinent - Bowel incontinent all (or almost all) of the time Appliances/Programs (Check all that apply)  FORMCHECKBOX  a. External (condom) catheter  FORMCHECKBOX  d. Ostomy present  FORMCHECKBOX  b. Indwelling catheter  FORMCHECKBOX  e. Scheduled toileting/other program  FORMCHECKBOX  c. Pads/briefs  FORMCHECKBOX  f. None of the Above SECTION M: Balance Accidents (Check all that apply)  FORMCHECKBOX  a. Fell in past 30 days  FORMCHECKBOX  d. Other fracture in last 180 days  FORMCHECKBOX  b. Fell in past 31-180 days  FORMCHECKBOX  e. None of the Above  FORMCHECKBOX  c. Hip fracture in last 180 days Danger of Fall (Check all that apply)  FORMCHECKBOX  a. Has unsteady gait  FORMCHECKBOX  b. Has balance problems when standing  FORMCHECKBOX  c. Limits activities because person or family fearful of person falling  FORMCHECKBOX  d. None of the Above SECTION N: Oral/Dental Status Oral Status and Disease Prevention (check all that apply)  FORMCHECKBOX  a. Has dentures or removable bridge  FORMCHECKBOX  b. Some/all natural teeth lost-does not have or does not use dentures(or partial)  FORMCHECKBOX  c. Broken, loose, or carious teeth  FORMCHECKBOX  d. Inflamed gums (gingiva); swollen or bleeding gums; oral abscesses; ulcers or rashes  FORMCHECKBOX  e. None of the Above SECTION O: Skin Conditions 1. Skin problems (Check all that apply)  FORMCHECKBOX  a. Abrasions/ scrapes  FORMCHECKBOX  b. Burns  FORMCHECKBOX  c. Bruises  FORMCHECKBOX  d. Rashes, itchiness body lice, scabies  FORMCHECKBOX  e. Open sores or lesions  FORMCHECKBOX  f. None of the Above Pressure Ulcers Presence of an ulcer anywhere on the body? This would include an area of persistent skin redness (Stage 1), partial loss of skin layers (Stage 2), deep craters in the skin (Stage 3), and breaks in the skin exposing muscle or bone, (Stage 4) . 0 No 1 Yes  FORMDROPDOWN  Foot Problems Person or someone else inspects feet on a regular basis? 0 No 1 Yes  FORMDROPDOWN  One or more foot problems or infections such as corns, calluses, bunions, hammer toes, overlapping toes, pain, structural problems, gangrene toe, foot fungus, onychomycosis? 0 No 1 Yes  FORMDROPDOWN  SECTION P: Environmental Assessment NF, RCF, Hospital; If person resides in a facility such as a NF, RCF, or hospital, check here and proceed to Section Q  FORMCHECKBOX  Home Environment (Check any of the following that makes home environment hazardous or uninhabitable. If none apply, check None of Above. If temporarily in institution, base assessment on home visit)  FORMCHECKBOX  a. Lighting including adequacy of lighting, exposed wiring  FORMCHECKBOX  b. Flooring and carpeting (e.g., holes in floor, electric wires where client walks, scatter rugs)  FORMCHECKBOX  c. Bathroom and toiletroom environment (e.g., non-operating toilet, leaking pipes, no rails though needed, slippery bathtub, outside toilet)  FORMCHECKBOX  d. Kitchen environment (e.g., dangerous stove, inoperative refrigerator, infestation by rats or bugs)  FORMCHECKBOX  e. Heating and cooling (e.g., difficulty entering-leaving home)  FORMCHECKBOX  f. Personal safety (e.g., fear of violence, safety problem in going to mailbox or visiting neighbors, heavy traffic in street)  FORMCHECKBOX  g. Access to home (e.g., difficulty entering/leaving home)  FORMCHECKBOX  h. None of the above SECTION Q: Mood Indicators of Depression, Anxiety, Sad Mood Code for behavior in last 30 days irrespective of the assumed cause Indicator not exhibited Indicator of this type exhibited up to 5 days a week Indicator of this type exhibited daily or almost daily (6,7 days a week) Verbal Expressions of Distress Person made negative statements-e.g., Nothing matters; Would rather be dead; Whats the use; Regrets having lived so long; Let me die  FORMDROPDOWN  Repetitive questions-e.g., Where do I go? What do I do?  FORMDROPDOWN  Repetitive verbalizations, e.g., calling out for help., (God help me)  FORMDROPDOWN  Persistent anger with self or others-e.g., easily annoyed; anger at placement in nursing home; anger at care received.  FORMDROPDOWN  Self-deprecation-e.g., I am nothing; I am of no use to anyone.  FORMDROPDOWN  Expressions of what appear to be unrealistic fears-e.g., fear of being abandoned, left alone, being with others.  FORMDROPDOWN  Recurrent statements that something terrible is about to happen-e.g., believes he or she is about to die, have a heart attack.  FORMDROPDOWN  Repetitive health complaints-e.g., persistently seeks medical attention, obsessive concern with body functions.  FORMDROPDOWN  Repetitive anxious complaints/concerns (non-health related)-e.g., persistently seeks attention/reassurance regarding schedules, meals, laundry, clothing, relationship issues.  FORMDROPDOWN  Sleep-Cycle Issues Unpleasant mood in morning  FORMDROPDOWN  Insomnia/change in usual sleep pattern  FORMDROPDOWN  Loss of Interest Sad, pained, worried facial expressions-e.g., furrowed brows  FORMDROPDOWN  Crying, tearfulness  FORMDROPDOWN  Repetitive physical movements-e.g., pacing, hand-wringing, restlessness, fidgeting, picking.  FORMDROPDOWN  Withdrawal from activities of interest-e.g., no interest in longstanding activities or being with family/friends.  FORMDROPDOWN  Reduced social interaction.  FORMDROPDOWN  Mood Persistence One or more indicators of depressed, sad or anxious mood were not easily altered by attempts to cheer-up, console or reassure the person over the last 7 days. No mood indicators Indicators present, easily altered Indications present, not easily altered  FORMDROPDOWN  Mood Persons current mood status compared to persons status 180 days ago. No change Improved 2. Declined  FORMDROPDOWN  SECTION R. INSTRUMENTAL ACTIVITIES OF DAILY LIVING IADL SELF-PERFORMANCE CODES: INDEPENDENT: (with/without assistive devices) No help provided. INDEPENDENT WITH DIFFICULTY: Person performed task, but did so with difficulty or took a great amount of time to do it. ASSISTANCE/DONE WITH HELP: Person involved in activity but help (including supervision, reminders, and /or physical hands-on help) was provided. DEPENDENT/DONE BY OTHERS: Full performance of the activity was done by others. The person was not involved at all each time the activity was performed. Activity did not occur. IADL SUPPORT CODES: No support provided. Supervision/cueing provided. Set-up help only. Physical assistance was provided. Total dependence the person was not involved at all when the activity was performed. Activity did not occur. DAILY INSTRUMENTAL ACTIVITIES Code for level of independence based on persons involvement in the activity in the last 7 daysSELF PERFORMANCESUPPORTa. Meal Preparation: Prepared breakfast and light meals.  FORMDROPDOWN   FORMDROPDOWN b. Main Meal Preparation: Prepared or received main meal  FORMTEXT       times per week.  FORMDROPDOWN   FORMDROPDOWN c. Telephone: Used telephone as necessary, e.g., able to contact people in an emergency.  FORMDROPDOWN   FORMDROPDOWN d. Light Housework: Did light housework such as dishes, dusting (on daily basis), making own bed.  FORMDROPDOWN   FORMDROPDOWN  OTHER INSTRUMENTAL ACTIVITIES OF DAILY LIVING Code for level of independence based on persons involvement in the activity in the last 14 daysSELF PERFORMANCESUPPORTa. Managing Finances: Managed own finances, including banking, handling checkbook, paying bills.  FORMDROPDOWN   FORMDROPDOWN b. Routine Housework: Did routine housework such as vacuuming, cleaning floors, trash removal, cleaning bathroom, as needed.  FORMDROPDOWN   FORMDROPDOWN c. Grocery Shopping: Did grocery shopping as needed (excluding transportation).  FORMDROPDOWN   FORMDROPDOWN d. Laundry: Indicate In home  FORMCHECKBOX  Out Home  FORMCHECKBOX   FORMDROPDOWN   FORMDROPDOWN  TRANSPORTATION Check all that apply for level of independence based on persons involvement in the activity in the last 30 days FORMCHECKBOX  a. 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FORMCHECKBOX  b. Person needed arrangement for transportation to medical, dental appointments, necessary engagements, or other activities.  FORMCHECKBOX  c. Person needed transportation to medical, dental appointments, necessary engagements, or other activities.  FORMCHECKBOX  d. Person needed escort to medical, dental appointments, necessary engagements, or other activities.  FORMCHECKBOX  e. Activity did not occur. PRIMARY MODES OF TRANSPORTATION(a) Indoors(b) OutdoorsCode for the primary mode of locomotion for (a) indoors or (b) outdoors for the following list: 1. Cane, 2. Walker/crutch, 3. Scooter, 4. Wheelchair, 5. Activity does not occur  FORMDROPDOWN    FORMDROPDOWN   MEDICATION NAME AND DOSAGE2. RA3. Freq4. PRNExample: Coumadin 2.5 mg Humulin R 25 Units Robitussin 15 cc1 5 11W 1D PR 2 FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN Notes:  FORMTEXT       ELIGIBILITY DETERMINATIONNF LEVEL OF CARE NF. 1.  FORMCHECKBOX  Yes  FORMCHECKBOX  No: In section A, Nursing Services, items 1-8, did you code any of the responses with a 4 (i.e., services needed 7 days/wk)?  FORMCHECKBOX  Yes  FORMCHECKBOX  No: In Section A, items 9 (Ventilator/Respirator) did you code this response with a 2, 3 or 4 (treatment needed at least 3 days/wk)?  FORMCHECKBOX  Yes  FORMCHECKBOX  No: In Section A, item 10 (Uncontrolled seizure), did you code this response with a 1, 2, 3, or 4 (care needed at least once/wk)?  FORMCHECKBOX  Yes  FORMCHECKBOX  No: In Section A, item 11 (Therapies), was the total number of days of therapy 5 or more days/wk? e.  FORMCHECKBOX  Yes  FORMCHECKBOX  No: In Section E, (Physical Functioning/Structural Problems), were 3 or more shaded ADLs coded with a 3 (extensive assistance) or 4 (dependent) in self performance? *If the answer to any of these questions is Yes, then the person will be found medically eligible for NF level of care and will be scored a 3 or presumed to have a score of 3 or more.NF. 2. Professional Nursing Services: In Section A, Nursing Services, items 1-8, how many were coded with a 2 or 3 (service needed 3-6 days/week)? 0 No 1 Yes  FORMDROPDOWN  In Section A, item 11 (Therapies), was the total number of days of therapy 3 or 4 days/week? 0 No 1 Yes  FORMDROPDOWN  In Section B, items 1a-1e and 1g-1j (excluding 1f, monthly injection), did you code any of the responses with a 2? 0 No 1 Yes  FORMDROPDOWN  In Section B, items 2a-2d, did you code any of the responses with a 2? 0 No 1 Yes  FORMDROPDOWN  Compute the nursing services score from 2a-2d and enter it here. Total  FORMTEXT      NF. 3. Impaired Cognition Is Section C1a (short-term memory), coded with a  1 ? 0  No 1  Yes  FORMDROPDOWN  In section C2 (memory recall) are 1 or 2 boxes checked in C2a-C2d or is C2e. 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