729 S. Norton St., Corunna, MI Phone: (989) FAX: (989)

Transcription

1 729 S. Norton St., Corunna, MI Phone: (989) FAX: (989) Admission Request Completion of this form by the attending physician and return of the completed information to the facility is required before a patient will be admitted. Transfer patients from hospitals will have this information supplied by the transferring hospital. Please complete the information as completely as possible and if you are returning the forms by FAX, please include the patient s name on each page. If current information is on file regarding the patient, completion of our form in its entirety may not be necessary. A signed certification of nursing home need, signed by the physician is a requirement. (Please see the bottom of page 3). Please call the facility with any questions. This portion may be completed by patient s family or responsible party. Patient Name: Date Of Birth: Age: Marital Status: Sex: Religion: Last Hospital Admission & Discharge Date: Name Of Hospital: Responsible Party Name: Address: Telephone: Medicare #: Medicaid #: Blue Cross/Blue Shield #: Other Insurance: The Attending Physician Must Complete The Remainder Of The Information. Diagnosis: Allergies If Any: Current Treatment: Diet Order: pleasantviewmcf.org

2 Drugs: Name Dosage Mode Frequency Reason For Med Rehabilitation Potential: Poor Fair Good Treatments And Other Therapy: E.G. Oxygen, I.V., P.T., Dressings, Tube Feedings, Speech Therapy, Etc. Check if Present: Disabilities: Amputation limb(s) Prosthesis Paralysis R L Limb(s) Contractures Site(s) Incontinence: Bladder Catheter Bowel Colostomy Saliva Suctioning needed Impairments: Speech Hearing Vision Sensation Requires use of any adaptive equipment: Wheelchair Cane Crutches Walker Other

3 Activity tolerance limitations: None Med. Sev. Difficulty breathing: Oxygen/Amt. Difficulty swallowing: Suction/Freq. Difficulty eating: Needs help Partially fed Totally fed Tube feeding Gastrostomy I.V. therapy Behavior: Alcoholic Belligerent Suspicious Withdrawn Noisy Mental status:alert Forgetful Confused Communications: YES NO Speaks Writes Understands Speech Understands Gestures Understands English If Not English, State Language Spoken: Additional Pertinent Information: **Chest X-Ray Date Result **Required Test C.B.C. Date Result Urinalysis Date Result Please enclose, mail, or FAX Radiologist s and lab reports. Certification For Extended Nursing Home Care I certify that continued care in an extended care facility or nursing home is necessary for the following reason (s):

4 I estimate that the period of E.C.F. inpatient care will be days or indefinite. Continued E.C.F. care is for the same condition for which patient received inpatient hospital services yes no I will not care for this patient after admission to the nursing home. Physician Signature Date

5 MEDICAL HISTORY AND PHYSICAL EXAMINATION Last Name First Name Primary care Physician MEDICAL HISTORY (Order of recording) 1. Chief Complaint 2. Present Illness 3. Past History 4. Family History 5. Social History 6. Systemic Review PHYSICAL EXAMINATION (Order of recording) 1. General 2. Skin 3. Lymphatic 4. Eyes, Ears, Nose,Throat 5. Mouth 6. Neck

6 7. Chest 8. Heart-blood vessels 9. Abdomen 10. Genitalla, Vaginal, Rectal 11. Locomotor 12. Extremities 13. Neurological Diagnostic Impression Signature and Date: ADMITTING PROGRESS NOTE I certify that NF services are required to be given on an inpatient basis because of this patient's need for skilled or intermediate nursing care. This patient has been informed of his/her medical condition. If NO: Medical contraindication for informing of medical condition is: Dated: Signature:

7 MENTAL ILLNESS/INTELLECTUAL DISABILITY/RELATED CONDITION EXEMPTION CRITERIA CERTIFICATION Michigan Department of Health and Human Services (For Use in Claiming Exemption Only) INSTRUCTIONS: This form must be completed by a registered nurse, licensed bachelor or master social worker, licensed professional counselor, psychologist, physician's assistant or physician and signed and dated by a physician's assistant or physician. The patient being screened shall require a comprehensive LEVEL II evaluation UNLESS any of the exemption criteria below is met and certified by a physician's assistant or physician. Indicate which exemption applies. Patient Name Date of Birth Name of Referring Agency Referring Agency Telephone Number Referring agency Address (Number, Street, Building, Suite Number, etc.) City State Zip Code Exemption Criteria COMA: DEMENTIA: Specify the type of dementia: Yes, I certify the patient under consideration is in a coma/persistent vegetative state. Yes, I certify the patient under consideration has dementia as established by clinical examination and evidence of meeting ALL 5 criteria below. Yes, I certify the patient under consideration does not have another primary psychiatric diagnosis of a serious mental illness. Yes, I certify the patient under consideration does not have an intellectual disability, developmental disability or a related condition. 1. Has demonstrable evidence of impairment in short-term or long-term memory as indicated by the inability to learn new information or remember three objects after five minutes, and the inability to remember past personal information or facts of common knowledge. 2. Exhibits at least one of the following: Impairment of abstract thinking, as indicated by the inability to find similarities and differences between related words; has difficulty defining words, concepts and similar tasks. Impaired judgment, as indicated by inability to make reasonable plans to deal with interpersonal, family and job-related issues. Other disturbances of higher cortical function, i.e., aphasia, apraxia and constructional difficulty. Personality change: altered or accentuated premorbid traits. 3. Disturbances in items 1 or 2 above significantly interfere with work, usual activities or relationships with others. 4. The disturbance has NOT occurred exclusively during the course of delirium. 5. EITHER: a) Medical history, physical exam and/or lab tests show evidence of a specific organic factor judged to be etiologically related to the disturbance OR b) An etiologic organic factor is presumed in the absence of such evidence if the disturbance cannot be accounted for by any non-organic mental disorder. HOSPITAL EXEMPTED DISCHARGE: YES, I certify that the patient under consideration: 1) is being admitted after a hospital stay, AND 2) requires nursing facility services for the condition for which she/he received hospital care, AND 3) is likely to require less than 30 days of nursing services. Physician/Physician Assistant Signature Date Name (Typed or Printed) Telephone Number AUTHORITY: Title XIX of the Social Security Act COMPLETION: Is voluntary, but, if NOT completed, Medicaid will not reimburse the nursing facility. COPY DISTRIBUTION: ORIGINAL- Nursing Facility retains in Patient file COPY - Attach to form DCH-3877 and send to Local CMHSP COPY - Patient Copy or Legal Representative The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability. DCH-3878 (Rev. 9-16) Previous edition obsolete. 1

8 Instructions for DCH-3878 The DCH-3878 is to be used ONLY when the individual identified on a DCH-3877 as needing a LEVEL II evaluation meets one of the specified exemptions from LEVEL II evaluation. If the individual under consideration meets one of the following exemptions, she/he may be admitted (under preadmission evaluation) or retained (under Annual Resident Review) at a nursing facility without additional evaluation. However, a completed copy of the DCH-3878 must be attached to the DCH-3877 and sent to the local Community Mental Health Services Program (CMHSP). This form must be completed by a registered nurse, licensed bachelor or master social worker, licensed professional counselor, psychologist, physician s assistant, or physician, and signed and dated by a physician's assistant or physician. Complete the following information to match the DCH-3877: Patient Name, DOB, and Referring Agency (including agency address and telephone number). Use an "X" to indicate which exemption applies to the individual under consideration. DEMENTIA: Review the 5 criteria listed under the dementia exemption category. Do NOT check this exemption unless the individual meets all 5 criteria. Any individual who meets some, but not all 5 criteria will be subject to a LEVEL II evaluation. If the individual under consideration meets this exemption category, specify the type of dementia. Do not mark the Dementia Exemption if there is a primary diagnosis of a serious mental illness. Do not mark Dementia Exemption if there is a diagnosis of intellectual disability, developmental disability or a related condition. Dementia diagnoses include the following: 1. Dementia of the Alzheimer s Type 2. Vascular Dementia 3. Dementia due to Other General Medical Conditions 4. Substance - Induced Persisting Dementia 5. Dementia Not Otherwise Specified DCH-3878 (Rev. 9-16) Previous edition obsolete. 2