Resident Name Medicaid # - - If Pending Medicaid, Social Security # - - Medicare # Date of Birth / / Responsible Party. Responsible Party Address

Transcription

1 URSIG FACILIT LEVEL OF CARE REQUEST FOR ADMISSIO Resident ame Medicaid # - - Room # Room Certified for Medicaid es o If Pending Medicaid, Social Security # - - Medicare # Date of Birth / / Marital Status M W S D Male Female Responsible Party Responsible Party Address Relationship Diagnoses Living Arrangements Prior To Admission CHECK OE OL: ew Admit Date / / Readmit Date / / Pay Source Change Date / / (Last Admit Date / / ) Admission or Readmission From: Acute Care Hospital Free-Standing Psychiatric Hospital Home ICF/MR/DD ursing Facility Personal Care Home Other: 1

2 URSIG FACILIT LEVEL OF CARE REQUEST FOR ADMISSIO *PASRR LEVEL I FORM (AD IF APPLICABLE, THE LEVEL II FORM) MUST BE COMPLETED AD A COP FAXED WITH ALL EW ADMISSIOS AD ALL PA SOURCE CHAGES. Level I PASRR Date / / Level II PASRR Date / / Completed By Appropriate for F Placement? es o Completed By Verbal Determination Form (Mental Illness Only) Date / / Appropriate for F Placement? es o Completed By Inappropriate Referral Date / / Completed By F ame Physician ame Address Facility ID # Phone ( ) Physician Phone ( ) Fax # ( ) Physician License # MEDICATIOS Describe resident s medications: umber of Oral, Tube, Topical, Inhalers, Sprays, or Patches. List the name and frequency of any IV, SQ, or IM medications (include routine flushes), Routine Administration of Oxygen (i.e., new administration of oxygen or regulating oxygen, how often checking pulse oximetry, etc.) and ebulizer Treatments. Is resident capable of self-administering medications? es o If no, why 2

3 URSIG FACILIT LEVEL OF CARE REQUEST FOR ADMISSIO COGITIVE ABILITIES Comatose Memory Recall: Knows Own ame Knows Date/Time Knows Location Knows Staff If es, Proceed to Communication COMMUICATIO /HEARIG ABILITIES Hears Adequately Uses Speech to Communicate Hearing Aid Use Understands Verbal Direction VISIO PATTERS Vision Adequate Visual Limitations MOOD AD BEHAVIOR Wanders Physically Abusive Verbally Abusive Socially Inappropriate Resists Care 3

4 URSIG FACILIT LEVEL OF CARE REQUEST FOR ADMISSIO ACTIVITIES OF DAIL LIVIG Bed Mobility : Transfer : Independent es o Independent es o Hands on assist es o Hands on assist es o To/From Bed Chair Wheelchair Bedbound es o Ambulation : Bathing : Independent es o Independent es o Hands on assist es o Hands on assist es o Standby assist es o Standby assist es o Independent with device es o Back Arms Wheelchair per self es o Legs Hands Wheelchair assist es o Feet Dressing : Grooming : Independent es o Independent es o Hands on assist es o Hands on assist es o Pulling on pants Putting on shirt Hair ails Buttons, Zippers Prothesis Teeth Shaving Continuous Supervision/Cues Makeup Continuous Supervision/Cues Toileting : Independent es o Hands on assist es o Pericare Adjust Clothing On/Off Toilet Changing pads/briefs Manage ostomy/catheter Continuous Supervision/Cues ADL Comments 4

5 URSIG FACILIT LEVEL OF CARE REQUEST FOR ADMISSIO UTRITIOAL STATUS Type of Diet Regular Low Sodium Healthy Heart Other Height Weight Feeding Independent with Tray Set Up Receives Partial Hands on Assist to Eat Total Feed Continuous Verbal Cues Tube Feeding Required es o If es, Explain Amount Brand Frequency H20 Flushes & Frequency SKI CODITIOS umber of Decubitus Ulcers Type of Ulcer Stage 1 Stage 2 Stage 3 Stage 4 Pressure/Stasis Pressure/Stasis Pressure/Stasis Pressure/Stasis Treatment Other Skins Problems Treatment 5

6 THERAPIES URSIG FACILIT LEVEL OF CARE REQUEST FOR ADMISSIO Physical Therapy Occupational Therapy Speech Therapy Respiratory Therapy URSIG REHABILITATIO/RESTORATIVE CARE a. Range of Motion (Passive) b. Range of Motion (Active) c. Splint or Brace Assistance d. Bed Mobility e. Transfer f. Walking g. Dressing or Grooming h. Eating or Swallowing i. Amputation/Prosthesis Care j. Communication k. Toileting 6

7 URSIG FACILIT LEVEL OF CARE REQUEST FOR ADMISSIO Additional Safety/Health Information Pertinent to Admission (i.e., Wanderguard, bed/chair alarm, locked unit/building, full side rails, etc.) PLEASE FAX ALL PASRR IFORMATIO WITH EW ADMISSIO REQUESTS. I certify that the MAP-726A information was reviewed by me. I attest that the foregoing information is true, accurate and complete. / / R/LP Signature Date Person Faxing Request / / Date ( ) ( ) Telephone umber Fax umber 7