DMR – PROGRAM REVIEW COMMITTEE – REGION



DDS PROGRAM REVIEW COMMITTEEMEDICATION/PROGRAM REVIEW FACE SHEETDATE OF REVIEW FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ??Planning and Support Team (PST) please fill out page 1 of this form FORMCHECKBOX Initial Review (New or Changed) FORMCHECKBOX Periodic/Update/Paper Review FORMCHECKBOX Behavior Modifying Medication FORMCHECKBOX Restraint Procedure FORMCHECKBOX Restrictive ProcedureName FORMTEXT ?????DDS# FORMTEXT ?????DOB FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ??Residence FORMTEXT ?????Agency FORMTEXT ?????Day Program FORMTEXT ?????CM/Contact Person FORMTEXT ?????RN FORMTEXT ?????Program Author FORMTEXT ?????For Behavior Modifying Medications or Restrictive Procedure: Target Behavior List1. FORMTEXT ????? 4. FORMTEXT ?????2. FORMTEXT ?????5. FORMTEXT ?????3. FORMTEXT ?????6. FORMTEXT ?????DSM-5 DiagnosesClinical Disorders FORMTEXT ?????Cognitive and Personality Disorders FORMTEXT ?????General Medical Conditions FORMTEXT ????? Prescriber FORMTEXT ?????Date last seen by Prescriber FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ??MedicationList ALL Psychiatric MedicationCurrentDosageProposedRangeStatus-Check One:C=Current (PRC-Approved) A=Add (Needs PRC Approval) D/C=DiscontinuedConsentDate1. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX A FORMCHECKBOX D/C FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ??2. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX A FORMCHECKBOX D/C FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ??3. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX A FORMCHECKBOX D/C FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ??4. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX A FORMCHECKBOX D/C FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ??5. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX A FORMCHECKBOX D/C FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ??6. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX A FORMCHECKBOX D/C FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ??Restraint Procedures(Specify mechanical or physical and list each type)Status-Check One:See Codes AboveConsentDate1. FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX A FORMCHECKBOX D/C FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ??2. FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX A FORMCHECKBOX D/C FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ??3. FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX A FORMCHECKBOX D/C FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ??Restrictive Procedures(List each type)Status-Check One:See Codes AboveConsentDate1. FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX A FORMCHECKBOX D/C FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ??2. FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX A FORMCHECKBOX D/C FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ??3. FORMTEXT ????? FORMCHECKBOX C FORMCHECKBOX A FORMCHECKBOX D/C FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ??Required documentation that MUST be attached:1. FORMCHECKBOX Behavior Support Plan w/Functional Assessment5. FORMCHECKBOX Behavior Modifying Medication History Date of Plan FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ??6. FORMCHECKBOX TD Screen2. FORMCHECKBOX Behavioral Data & Graphs7. FORMCHECKBOX Consent Form(s) – Medication and/or Restrictive Proc.3. FORMCHECKBOX Psych/Prescriber Treatment Plan8. FORMCHECKBOX Response to Most Recent PRC Requirements/Suggestions Date of Plan FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ??9. FORMCHECKBOX List of Other Medications4. FORMCHECKBOX Psych/Prescriber Notes (Three (3) most recent) 10. FORMCHECKBOX Psychiatric Medication Data Entry FormName of Person Completing This Form FORMTEXT ?????Phone # FORMTEXT ?????Date FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ??NAME FORMTEXT ?????PRC DATE FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ??PROGRAM REVIEW COMMITTEE RECOMMENDATION Medication Range1. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Approved FORMCHECKBOX Disapproved FORMCHECKBOX Approved w/Qual2. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Approved FORMCHECKBOX Disapproved FORMCHECKBOX Approved w/Qual3. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Approved FORMCHECKBOX Disapproved FORMCHECKBOX Approved w/Qual4. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Approved FORMCHECKBOX Disapproved FORMCHECKBOX Approved w/Qual5. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Approved FORMCHECKBOX Disapproved FORMCHECKBOX Approved w/Qual6. FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Approved FORMCHECKBOX Disapproved FORMCHECKBOX Approved w/QualBehavioral Plan based on an Acceptable Functional Assessment: FORMCHECKBOX Yes FORMCHECKBOX NoBehavior Program: FORMCHECKBOX Approved FORMCHECKBOX Disapproved FORMCHECKBOX Approved with QualificationsQualifications/Requirements FORMTEXT ?????Suggestions (Not required) FORMTEXT ?????T D Screen Date: FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ?? FORMCHECKBOX AIMS FORMCHECKBOX DISCUS FORMCHECKBOX OTHER FORMCHECKBOX RESULTS: FORMTEXT ?????__________PRC Members SignaturesTeam Members Attending____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Type of the Next PRC Review FORMCHECKBOX Presentation FORMCHECKBOX Paper ReviewNext PRC Date FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ?? Referred to DDS Human Rights CommitteeDate: FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ?? Reason for Full HRC Review FORMTEXT ?????REGIONAL DIRECTOR’S DECISIONMedication FORMCHECKBOX Approved FORMCHECKBOX Disapproved FORMCHECKBOX Approved with QualificationsProgram FORMCHECKBOX Approved FORMCHECKBOX Disapproved FORMCHECKBOX Approved with QualificationsComments/Qualifications/Requirements (attach additional comments as necessary) FORMTEXT ????? FORMCHECKBOX Additional Comments AttachedRegional Director’s Signature: __________________________________________________Date: FORMTEXT ??/ FORMTEXT ??/ FORMTEXT ?? ................
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