Contact Us 888-287-2443 MEDICALLY FRAGILE NURSING ASSESSMENT AND MONITORING TOOL Member last name First name Middle name Medicaid number Street address Date of birth City County State OK Zip Nurse completing document (please print or type) Date completed Nurse agency Case management agency Date sent to case manager Case manager (please print or type) VISIT TYPE Initial nurse evaluation interdisciplinary team meeting (IDT) (complete pages 1-10) Reassessment IDT (complete pages 1-10) 6 month evaluation (complete pages 1-10) Personal care aide (PCA) supervisory visit (complete pages 1-10) Monthly advanced supportive/restorative (ASR) supervision (complete pages 1-4, 9-10) Skilled nurse (SN) visit (complete box below) (complete pages 1-4) Reason for skilled nurse visit (check all that apply) Fill med box Foot care Wound care Catheter change Lab draw DIAGNOSES Diabetes Stroke Cardiopulmonary disease (COPD) Heart disease Cancer OKHCA Revised 06-19-2012 Med Frag 6 page 1 of 11
Visit to any of the following in the past 6 months? (check all that apply) Hospital Dates: Comments Emergency room Comments Dates: Nursing facility Comments Dates: Behavioral health facility Comments Dates: Physicians or Health Practitioners Physician name Specialty Date last seen Phone OKHCA Revised 06-19-2012 Med Frag 6 page 2 of 11
ASSESSMENT Vital signs: Height: Weight: Blood pressure: / Pulse: Respirations: Neurological Mental or behavioral health Integument Cardio pulmonary Nutrition Elimination Mobility Sleep Pain Details specific to member s current chronic health conditions (attach page if needed) OKHCA Revised 06-19-2012 Med Frag 6 page 3 of 11
Equipment or supplies member is currently using (check all that apply) Cane Wheelchair Walker Glasses Dentures Hearing aid Shower chair Hand held shower Grab bars Bedside commode Incontinent supplies Personal Emergency Response System (PERS) Details of skilled care provided: Member's response to care: Medications (attach additional page if necessary) Name of medication Dose Route Frequency Purpose Date Filled Physician Pharmacy: Phone: Allergies: Medication administered by: Self Other (list name and relationship): Uses Med Planner: Yes, filled by: No Signature of member or legal agent Date Signature of nurse Date (if member signs with a mark, two witnesses are required) OKHCA Revised 06-19-2012 Med Frag 6 page 4 of 11
Signature of witness Date Signature of witness Date Needs Assessment Summary Key: Who: S=Self I=Informal O=Other P=Personal care aide or personal services aide (PCA/PSA) Frequency (Freq): How often is assistance needed? Hours per week: If PCA or PSA performs or assists with task, designate the amount of time needed. Activities of Daily Living Instrumental Activities of Daily Living Task Who Freq Dressing Bathing Grooming Hours per week Task Who Freq Shopping & errands Meal preparation Housekeeping Hours per week Toileting Eating Mobility & transfer Standby assist Laundry Money management Telephone Heavy chores Medication assist Transportation Respite Respite provided by: Comments: Hours/wk: OKHCA Revised 06-19-2012 Med Frag 6 page 5 of 11
ASR or Advanced Personal Services Assistant (APSA) Tasks Hours per week: Transfers Specialty lift Catheter care Ostomy care Range of motion Bowel program Safety Concerns No concerns Health status Recent fall Change in supports Environment Unmet supervision needs Change in mental status Equipment needs Unintentional weight loss Finances Active adult protective services (APS) case How long can member be home alone? Unlimited Short periods Requires 24/7 supervision (If "Unlimited" is not checked, please explain why in the comment box below) Comments: Current other agency involvement? Yes No List name, service provided, and contact information: OKHCA Revised 06-19-2012 Med Frag 6 page 6 of 11
Resources Medicare Private health insurance: State Plan Veterans Benefits Vocational Rehabilitation Hospice: Private Pay Indian Health Services Community Organization: Independent Living Center Comments: OKHCA Revised 06-19-2012 Med Frag 6 page 7 of 11
Recommendations Adult Day Health Respite Home Delivered Meals Hospice 24 hour supervision Mental health referral Nutritional Supplements Dietitian SN (include recommended tasks) ASR SN monitoring PERS Therapy: Occupational Physical Speech Environmental modifications (describe): Comments: Equipment and supply needs: Signature of member or legal agent (if member signs with a mark, two witnesses are required) Date Signature of witness Date Signature of witness Date Signature of nurse Date Signature of case manager Date OKHCA Revised 06-19-2012 Med Frag 6 page 8 of 11
PSA/APSA/PCA/ASR Supervisory Visit Report Required Name(s) of current worker(s): Relationship to member: Does paid caregiver reside with member? Yes No Was PCA/ASR present at time of visit? Yes No Amount of time allotted for PCA/PSA tasks: Amount being delivered: Amount of time allotted for ASR/APSA tasks: Amount being delivered: Assigned tasks: Bed bath Tub bath Shower Shampoo Hair care Skin care Standby assist Meal prep Advanced meal prep Dusting Sweeping Mopping Vacuuming Clean bathroom Clean kitchen Dishes Trash removal Bed making Laundry Errands ASR/APSA Tasks: Transfers Specialty lift Catheter care Ostomy care Range of motion Bowel program Details of ASR/APSA tasks performed: Are PCA/ASR s current skills adequate to perform tasks? Yes No (specify): OKHCA Revised 06-19-2012 Med Frag 6 page 9 of 11
Questions for the Member or Responsible Party Are the above tasks performed to your satisfaction? Yes No Sometimes Does the aide stay the entire time allotted? Yes No Sometimes Are you contacted if the aide is unable to come at the scheduled time? Yes No Sometimes Does the agency offer to send a replacement aide? Yes No Sometimes Who do you contact if an aide does not show up? If a replacement aide is not available, what is your back up plan? Do you feel respected by the aide? Yes No Sometimes Is the current service plan meeting your needs? Yes No Sometimes Nurse s recommendations No change Increase services Decrease services Justification Signature of member or legal agent Date Signature of nurse Date (if member signs with a mark, two witnesses are required) Signature of witness Date Signature of witness Date Signature of PCA/ASR Date Signature of PCA (if present) Date OKHCA Revised 06-19-2012 Med Frag 6 page 10 of 11
sign2 Member last name First name Middle name Medicaid number OKHCA Revised 06-19-2012 Med Frag 6 page 11 of 11