Nursing Care Consultant Assessment



DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA)Nursing Care ConsultantAssessmentDATE OF REVIEW FORMTEXT ????? FORMCHECKBOX ANNUAL FORMCHECKBOX INITIAL FORMCHECKBOX SIX (6) MONTHDATE OF LAST REVIEW FORMTEXT ?????PRISM SCORESCURRENT PRISM SCORE: FORMTEXT ?????PREVIOUS PRISM SCORE: FORMTEXT ?????ADMIT RISK SCORE: FORMTEXT ?????PREVIOUS ADMIT RISK SCORE: FORMTEXT ?????TPL / MCO: FORMTEXT ?????Client Demographic InformationCLIENT’S NAME FORMTEXT ?????SEX FORMCHECKBOX Male FORMCHECKBOX FemaleAGE FORMTEXT ???DATE OF BIRTH FORMTEXT ?????ADSA NUMBER FORMTEXT ?????ADDRESS FORMTEXT ?????PARENT / GUARDIAN’S NAME FORMTEXT ?????TELEPHONE NUMBER FORMTEXT ?????INDIVIDUALS PRESENT FOR ASSESSMENT FORMTEXT ?????FAMILY / INFORMAL SUPPORT FORMTEXT ?????NURSE / NURSING AGENCY / AGENCIES FORMTEXT ?????CURRENT NURSING HOURS FORMTEXT ?????TELEPHONE NUMBER(S) FORMTEXT ?????CLINICAL SUPERVISOR FORMTEXT ?????TELEPHONE NUMBER FORMTEXT ?????CASE RESOURCE MANAGER FORMTEXT ?????TELEPHONE NUMBER FORMTEXT ?????PERSONAL CARE HOURS FORMTEXT ?????RESPITE HOURS FORMTEXT ?????PERSONAL CARE PROVIDER FORMTEXT ?????PROVIDERSPECIALTYLAST VISITOUTCOME FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????CODE STATUS FORMTEXT ?????DIAGNOSESALLERGIESWEIGHT FORMTEXT ?????HEIGHT FORMTEXT ?????VACCINATIONSInfluenza? FORMCHECKBOX Yes FORMCHECKBOX NoPneumococcal? FORMCHECKBOX Yes FORMCHECKBOX No Comments below:Laboratory Work 911 / ED Visits / Hospitalizations / IllnessesUpcoming Surgeries / ProceduresMedicationsUpdates / changes: CommunicationVerbal communication:Method(s) of communication:Ability to express wants / needs:Ability to ask for help in the event of an emergency:Comments:Community InclusionSchool name and schedule:Activities / interests:Comments:MusculoskeletalMusculoskeletal limitation:Mobility:Equipment used:Equipment needed:OT? FORMCHECKBOX Yes FORMCHECKBOX No PT? FORMCHECKBOX Yes FORMCHECKBOX NoSLP? FORMCHECKBOX Yes FORMCHECKBOX No PROM? FORMCHECKBOX Yes FORMCHECKBOX NoComments: RespiratoryVented: FORMCHECKBOX Yes FORMCHECKBOX NoVent schedule:Trach: FORMCHECKBOX Yes FORMCHECKBOX No. If Yes, reason:1Trach change frequency:Who does the trach change: Trach care frequency:Trach suctioning frequency:Oral suctioning frequency:Nasal suctioning frequency:Requires oxygen: FORMCHECKBOX Yes FORMCHECKBOX NoOximeter frequency:Passy Muir Valve (PMV) use / tolerance:Heated Moisture Exchange: FORMCHECKBOX Yes FORMCHECKBOX NoCapping use / tolerance:Nebulizer:Cough assist:Respiratory vest / manual CPT:CPAP / BIPAP:Resuscitation within the last year: FORMCHECKBOX Yes FORMCHECKBOX NoComments:Genitourinary / GastrointestinalDiet:Oral feeder: FORMCHECKBOX Yes FORMCHECKBOX NoJT: FORMCHECKBOX Yes FORMCHECKBOX NoGT: FORMCHECKBOX Yes FORMCHECKBOX NoWho does the tube change:Stoma care frequency:Tube feeding schedule and rate:Venting schedule:Farrell bag:Measurement of I & O:Continent of bowel: FORMCHECKBOX Yes FORMCHECKBOX NoBowel program: FORMCHECKBOX Yes FORMCHECKBOX NoContinent of bladder: FORMCHECKBOX Yes FORMCHECKBOX NoUse of catheter: FORMCHECKBOX Yes FORMCHECKBOX NoMenstrual cycle:Comments:NeurologyHistory of seizures / type / frequency / intervention: Pain type / location / relieved by: Comments: CardiacEndocrinologyVascularCentral lines: FORMCHECKBOX Yes FORMCHECKBOX NoComments:IntegumentarySkin integrity / pressure injuries: History of pressure injuries:Skin Observation Protocol triggered: FORMCHECKBOX Yes FORMCHECKBOX NoDate: FORMTEXT ?????Who was SOP referred to:Wound care:Comments:Emergency PreparednessCorrect size of AMBU bag for resuscitation (what size): FORMCHECKBOX Yes FORMCHECKBOX NoNeonatal: FORMCHECKBOX Yes FORMCHECKBOX No Pediatric: FORMCHECKBOX Yes FORMCHECKBOX NoAdult: FORMCHECKBOX Yes FORMCHECKBOX NoEmergency To Go Bag: FORMCHECKBOX Yes FORMCHECKBOX NoBack-up ventilator / concentrator: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ABack-up batteries: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AGenerator: FORMCHECKBOX Yes FORMCHECKBOX NoAre you connected with local police / fire departments / Smart 911: FORMCHECKBOX Yes FORMCHECKBOX NoComments:Client Observation at Time of VisitIssues / ConcernsNCC RecommendationsCLINICAL CRITERIA TOOL SCORERECOMMENDATIONSThe information in this document, from my observations, is true and accurate. The information in this document, as reported to me, is accurately recorded.SIGNATUREDATE FORMTEXT ????? FORMTEXT ?????TITLE FORMTEXT ?????INITIALS FORMTEXT ????? ................
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