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CONTENTS Foreword by Josh Hardie, CBI 04 Foreword by Rod Bristow, Pearson 05 Executive summary 06 1 The ninth education and skills survey 10
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MEDICAL CERTIFICATION FOR NURSING FACILITY/HOME- AND COMMUNITY-BASED SERVICES FORM (Replaces Patient Transfer and Continuity of Care Form) (A)
FACILITY INFORMATION
Facility From _____________________________ Admission Date
Facility To _____________________________
(B)
______/______/______
Discharge Date ______/______/______
(E)
HISTORY & PHYSICAL AND LABS
1. PHYSICAL EXAM (History & Physical may be attached) Head Ears Eyes Nose & Throat (HEENT)
Abdomen Individual's Last Name First Name Initial _______________________________________________________________________________ GU Rectal Individual's Address Phone Number _______________________________________________________________________________ Extremities Neurological Nearest Relative/Health Care Surrogate Phone Number Other
PHYSICIAN INFORMATION Name
Free from communicable diseases
Yes
No
Will you care for individual in NF? Yes No 2. LABORATORY FINDINGS (Reports may be attached) Yes No Date _______/_______/_______ If no, referred to __________________________________________________________________ TB Test Principal Diagnosis ______________________________________________________________ Results Secondary Diagnosis ____________________________________________________________ Chest X-Ray
Yes
No
Date _______/_______/_______
Discharge Diagnosis _____________________________________________________________ Results (Problem List may be attached) Surgery Performed & Date
MEDICATION AND TREATMENT ORDERS (copies may be attached)
(G)
Date _______/_______/_______ Date _______/_______/_______ Date _______/_______/_______ Date _______/_______/_______
PHYSICAL THERAPY (Attach Orders) New Referral
Continuation of Therapy
(C) PREADMISSION SCREENING FOR MENTAL ILLNESS/MENTAL RETARDATION (Complete for admission to NF only) 1. Is dementia the primary diagnosis? Yes 2. Is there an indication of, or diagnosis of mental retardation (MR), or has the individual received MR services within the last 2 years? Yes 3. Is there an indication of, or diagnosis of serious mental illness (MI), such as (check all that apply) Schizophrenia Panic or severe anxiety disorder Mood disorder Personality disorder Somatoform disorder Other psychotic or mental disorder Paranoia leading to chronic disability 4. Has the individual received MI services within the past two years? Yes 5. Is the individual a danger to self or others? (please attach explanation) Yes 6. Is the individual on any medication for the treatment of a serious Yes mental illness or psychiatric diagnosis? 7. If yes, is the MI or psychiatric diagnosis controlled with medication? Yes 8. Is the individual being admitted from a hospital after receiving acute Yes inpatient care? 9. Does the individual require nursing facility services for the condition Yes for which he/she received care in the hospital? 10.Has the physician certified the individual is likely to require less than Yes 30 days of nursing facility services?
(D)
No No
No No No
FREQUENCY OF THERAPY INSTRUCTIONS Stretching Passive Range of Motion (ROM) Active assistive Active Progressive resistive PRECAUTIONS Cardiac Other
Sensation Impaired: Restrict Activity:
Progress bed to wheelchair Recovery to full function Wheelchair independent Complete ambulation Yes Yes
No No
ADDITIONAL THERAPIES (Attach Orders)
No No No
Coordinating Activities Non-weight bearing Partial weight bearing Full weight bearing
Occupational Therapy Speech Therapy
Respiratory Therapy Other
(H) TREATMENT AND EQUIPMENT NEEDS (Attach Orders)
Catheter Care Changing Feeding Tube Dressing Changes Ostomy Care Wound Care Suctioning Trach Care
No
ADDITIONAL ORDERS (Orders may be attached)
Diabetic Care Monitor Blood Sugar/Frequency Administer Insulin Tube Feeding Oxygen (Select from below) PRN Continuous @L/min
Instructions
(I)
(J)
SPECIAL DIET ORDERS (Orders may be attached)
TYPE OF CARE RECOMMENDED (MUST BE COMPLETED AND SIGNED)
Check one
Rehab Potential (check one)
Good
Fair
Poor
Skilled Nursing Extended Care Facility (ECF), Duration ______________ Intermediate Care: Duration ____________________ Admission Date to Nursing Facility _______/_______/_______ I certify that this individual requires ECF Nursing Facility Care for the condition for which he/she received care during hospitalization. I certify that this individual is in need of Medicaid Waiver Services in lieu of Institutional placement. Effective Date of Medical Condition_______/______/_______
Print Physician's Name Address Phone Number
Fax
Email Contact Address
FOR ONLINE APPLICANT USE ONLY IF APPLYING FOR MEDICAID, PLEASE INCLUDE DCF
Physician's Signature and Date Required AHCA MEDSERV-3008 form, May 2009--(Replaces Patient Transfer and Continuity of Care Form 3008 July 2006 - CF Med 3008)
ACCESS CONFIRMATION NUMBER BELOW:
NURSING/SOCIAL WORK ASSESSMENT [Page 2 may be completed by a Nurse or Social Worker] INDIVIDUAL'S NAME _____________________________________________ (K) VISION (w/glasses if used) HEARING (w/aid if used)
1. Transmits messages/receives information 2. Limited ability 3. Nearly or totally unable
MENTAL AND BEHAVIOR STATUS
2. Needs intermittent rest
3. Rarely tolerates short acitivities
3. Poor
COMMUNICATION
ADLs ARE AT TIME OF NF ADMISSION
1. No assistance 2. Assistance with difficult maneuvering
3. Wheels a few feet 4. Unable N/A
1. Alert
5. Aggressive
9. Safety restraints needed
1. No assistance
A- Bathroom
2. Confused
6. Disruptive
10. Well motivated
2. With assistive devices
B - Bedside commode
3. Disoriented 4. Comatose
7. Apathetic 8. Wanders
3. With supervision 4. Requires assistance
C- Bedpan
TOILETING
5. Total assistance
SKIN CONDITION
1. Intact
5. Decubitus
2. Dry/Fatigue
Site:__________________
1. Continent
3. Irritations (rash)
Stage:_________________
4. Open Wound
Size:__________________
BLADDER CONTROL
1. No assistance
DRESSING
2. Occasional incontinence - once/week or less 3. Frequent incontinence - up to once a day 4. Total incontinence 5. Catheter - indwelling
1. Continent
2. Supervision
BOWEL CONTROL
3. Requires assistance* 4. Has to be dressed
2. Occasional incontinence-once/week or less 3. Frequent incontinence - up to once a day 4. Total incontinence 5. Ostomy
BATHING
1. No assistance
A- Tub
2. Supervision
B - Shower
3. Requires assistance*
C- Sponge Bath
1. No assistance
FEEDING
4. Is bathed
TEACHING NEEDS
5. Aspirates
2. Tray set up only 3. Requires assistance 4. Is fed
1. Diabetic
3. Ostomy
2. Cardiac
4. Other (specify):
DIET
1. Full
3. Pureed
2. Mechanical Soft
4. Other (specify):
*(HANDS ON NEEDED) Comments:___________________________________________________________________________________________________________________
SIGNATURE AND TITLE________________________________________________________________________DATE_________/_________/_________ (L)
SOCIAL WORK ASSESSMENT
Prior Living Arrangement_______________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ Long Range Plan/Agency Referrals_______________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ Adjustments to Illness or Disability_______________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ Comments ___________________________________________________________________________________________________________________
AHCA MEDSERV-3008 form, May 2009--(Replaces Patient Transfer and Continuity of Care Form 3008 July 2006 - CF Med 3008)
