Oregon Needs Assessment Field Notes Tool



ASSESSMENT & DEMOGRAPHIC INFORMATIONName: ____________________________ Sex: _______Birthdate: ___________Age: ____Prime#: ___________Phone: _______________Address/#:_____________________________________ Interview Date: ________________________________ FR Date: ______________________________________Face-to-Face Observation Date: ___________________Assessment Completion Date: ____________________Guardian name/#: ______________________________Vision: Adeq____ M-M_____ Sev_____ Unable_____ Hearing: Adeq___ M-M_____ Sev_____ Unable____Element #: ________ Child CM/#: __________________SC/PA: ____________________ County: ____________Individual Participation level: _________________________________________________________________People who attended and/or contributed:(name/#/email, relationship, participation, live w/)_______________________________________________________________________________________________________________________________________COMMUNICATION1(a) How does the individual Communicate w/others? Verbal English\Verbal Spanish\Other Verbal\Sign Language\Writing/Braille \Gestures\Facial Expressions\Communication Board\Electronic Device\ Texting/Email/Social Media\Other_____________________________________________1(b) How do others Communicate w/the individual? Verbal English\Verbal Spanish\Other Verbal\Sign Language\Writing/Braille \Gestures\Facial Expressions\Communication Board\Electronic Device\ Texting/Email/Social Media\Other _____________________________________________2(a) Clarity of speech:Always Clear \ Occasionally Unclear \ Frequently Unclear\ Never Clear\Does not Speak \ Unable to Assess____________________________________________2(b) Expression of ideas w/familiar people:Expresses Complex messages without difficulty \ Exhibits some difficulty expressing needs and ideas. E.g. some words or finishing thoughts. \ frequently exhibits difficulty expressing needs and ideas \ Rarely/Never expresses self \ Unable to assess_____________________________________________2(c) Expression of ideas w/unfamiliar people: Expresses Complex messages without difficulty \ Exhibits some difficulty expressing needs and ideas. e.g. some words or finishing thoughts. \ Frequently exhibits difficulty expressing needs and ideas \ Rarely/Never expresses self \ Unable to assess_____________________________________________2(d) Can ask for Drink or indicate thirst: Y/N _________ 2(e) Understanding verbal content: Clear Understanding \ Usually Understands (most of message) \ Sometimes understands (basic conversations, simple direct phrases) \ Rarely/Never Understands \ Unable to assess_____________________________________________ACTIVITIES OF DAILY LIVING (ADLs)Coding: Independent \ Setup or Clean-up Assistance \ Supervision or Touching Assistance \ Partial/Moderate Assistance \ Substantial/Maximal Assistance \ Dependent \ Person Refused \ Not Applicable \ Not Attempted3. Dressing-skip under 4yo: (a) Upper body: ________________________________ (b) Lower body: ________________________________(c) Footwear: __________________________________ (d) Preferences:Changes clothes multiple times dailyChoose own clothes Female support personMale support personSame clothing daily Velcro closuresWears loose clothingOther FORMTEXT ????? FORMTEXT ?????(e) Guidance:Able to direct support person Behavioral health challenges Can button clothingCan lift arms Medical/physical symptoms interfere with performing taskPersons providing support dress individual’s lower bodyPersons providing support dress individual’s upper body Gets dressed with cueing Persons providing support help select appropriate, clean, and/or matching clothes Persons providing support label/organize clothing by color, style, etc. Able to manage his/her own needPersons providing support put on/take off footwearPersons providing support put on/take off sock/TED hoseTwo-person assistAble to tie Able to zipUses assistive deviceWill attempt to wear dirty clothesOther FORMTEXT ????? FORMTEXT ?????#3 Notes:4. Transfer/Position-skip under 3yo: (a) Sit ?Stand: _________________________________(b) Chair/Bed ?Chair: ___________________________(c) Roll left and right: ____________________________(d) Preferences:Support persons use a gait beltSomeone to assistMechanical and/or ceiling liftsUse a transfer board/poleWeight bearing transferOther FORMTEXT ????? FORMTEXT ????? (e) Guidance:Asks for assistancePersons providing support assist with all wheelchair transfersBehavioral health challenges Can transfer self-using a liftPersons providing support cue to use adaptive equipmentMedical/physical symptoms interfere with performing taskHas good upper body strengthPersons providing support maintain contact until steadyIndividual able to manage his/her own needRegular repositioning requiredPersons providing support should talk individual through each transferTransfer quicklyTransfer slowlyTransfers with some supportTwo-person transferSteady during transferUse mechanical lift for ALL transfersUse transfer board for transfersOther FORMTEXT ????? FORMTEXT ?????#4 Notes:5. Mobility (a) Does Ind Walk-skip under 3yo: ? Y ? N Walking Goal: ? Y ? N (b) Walk 150ft-skip under 3yo: ___________________(c) On/off curb-skip under 3yo: ___________________(d) Up/Down 12 steps-skip under 3yo: __________________________________________________________________________________________(e) Wheelchair/Scooter-skip under 3yo: ? Y ? N, Unmet need ? N, Does not use Type: Man/Motor/Both(f) Wheels 150ft-skip under 3yo: _________________(g) 2+ falls in past year: ? Y ? N ? Unknown Falls cause major inj: ? Y ? N ? Unknown (h) Type of injury: Fracture \ Head Injury \ other (describe)_____________________________________________(i) Preferences:Can walk, but prefers wheelchair Cane Contact guard when walking Crutch Electric wheelchair Gait belt Manual wheelchair Pushed in wheelchair Walker Walker with fold-down seat Walker with permanent seatOther: FORMTEXT ????? FORMTEXT ?????(j) Guidance:Access to backup equipment or same day repair necessaryIndividual is afraid of falling Persons providing support should assist individual over thresholds Can self-propel wheelchairBehavioral health challenges Medical/physical symptoms interfere with performing task Evacuation plan: call neighbor or friendEvacuation plan: support person assistance Evacuation plan: use personal emergency response system (PERS)Has a steady gait Persons providing support keep walkways clearIndividual leans to one side Persons providing support leave assistive device within reachIndividual able to manage his/her own need Good navigationPersons providing support provide contact guard when walkingPersons providing support provide physical support with stairsPersons providing support should remind individual to use assistive deviceBatteries recharged daily by support personSees well enough to navigate independently Two-person assistAble to exit in emergencyAble to walk/bear weightPersons providing support hold the gait belt to steady the individual Other: FORMTEXT ????? FORMTEXT ?????#5 Notes:6. Eating/Tube Feeding: (a) Nutritional Approaches: Parenteral/IV \ Feeding Tube \ Mechanically altered \ None(b) Eating-skip under 4yo: _______________________ (c) Tube: _____________________________________(f) Does the individual have any signs or symptoms of a possible swallowing disorder? Pain w/swallowing \ Coughing/choking while eating \ Holding food in mouth/cheeks \ Loss of liquids/solids from mouth \ NPO \ Other \ None(g) Does Ind. refuse foods due to preferences or sensory issues, such as texture or taste: ? Y ? N If Yes, describe: __________________________________________________________________________________________________________________________(h) Does the ind. drool excessively: ? Y ? N (i) Does the Ind. c/o chest pain, heartburn, or have small, frequent vomiting or unusual burping: ? Y ? N (j) Has the Ind. required intravenous (I/V) fluids due to dehydration in the last year: ? Y ? N (d) Preferences:Bland diet Cold food Eat/tube feed alone Eat/tube feed with others present Finger foodsHot food Large portions Small portions SnacksUse own recipesSupport person to inject formula slowlyTube feeding to be done discretelyEnvironmental preferences – likes to be warm, watch TV, etc. Other FORMTEXT (e) Guidance:Behavioral health challenges Can cut food Persons providing support cut food into small pieces Medical/physical symptoms interfere with performing task Has a good appetite Independent with equipment/adaptationsIndividual has food allergiesPersons providing support monitor liquids Individual has mouth painPersons providing support provide cues for eatingUses tube feeding pumpUses gravity methodUses syringe methodStrategic timing of tube feeding to maximize participation in other activitiesMust stop and start tube feeding process frequently - tube clogs easily, person gets up frequently, etc. Two-person assistOther: FORMTEXT ????? FORMTEXT ?????#6 Notes:7. Elimination: (a) Toilet hygiene-skip under 4yo: _________________(b) Toilet transfer-skip under 4yo: _________________(e) Issues around constipation in last year: ? Y ? N (f) Routine or PRN medications for constipation 2 or more x’s a month in the last year (not fiber): ? Y ? N (g) Does Ind. have a diagnosis of chronic constipation or ongoing issues with constipation: ? Y ? N (h) Required a suppository or enema in past year: ? Y ? N (i) Digital impaction removal 5 or more days/week: ? Y ? N (j) More than 1 painful bowel movement in past year: ? Y ? N (k) More than 1 episode of hard stool in past year: ? Y ? N (l) Takes medication that causes constipation and wouldn’t recognize/communicate if constipated: ? Y ? N __________________________________________________________________________________________(c) Preferences:Adult protection/absorbent productsDiapersBed pan onlyBedside commodeFemale support personMale support personPads/briefs when going outSpecific productsUrinalOther FORMTEXT ????? FORMTEXT ?????(d) Guidance:Able to use incontinence products Assists support person with transferAware of need to use toiletBehavioral health challenges Persons providing support provide assistance finding the bathroomAble to change incontinence pads Able to complete own perineal care Able to empty ostomy/catheter bagDoes not need assistance at nightExperiences urgency Painful urination Will use pads/briefsTwo-person assistCondom catheter used with support person assistancePads changed by support person, as neededMedical/physical symptoms interfere with performing task Other FORMTEXT ????? FORMTEXT ?????#7 Notes:8. Showering and Bathing-skip under 5yo: (a) Shower/bathe self: _______________________________________________________________________ (b) Preferences:Bath Bed bath Female support personMale support personShower Sponge bathSpecific productsOther FORMTEXT ????? FORMTEXT ?????(c) Guidance:Able to direct support person Able to manage his/her own needs Afraid of bathingPersons providing support assist with drying and dressing Bathes self with cueingBehavioral health challenges Can be left unattended Can judge water temperature Can adjust water temperatureMedical/physical symptoms interfere with performing task Enjoys bathingPersons providing support give bed/sponge bathIndividual is weight bearingSkin checks are completed by support personPersons providing support soak the individuals’ feet Standby during bathing Two-person assistAble to transfer in/out of tub/showerAble to shampoo hairAble to stand alonePersons providing support wash the individuals back, legs, feetOther FORMTEXT ????? FORMTEXT ?????#8 Notes:9. Oral Hygiene-skip under 5yo: (a) Oral Hygiene: ____________________________________________________________________________Dentures: ? Y ? N _________________________________________________________________________ (b) Preferences:Assistance after eatingAssistance during morning routineAssistance before bedtimePrefers a female support personPrefers a male support personElectric toothbrushOther FORMTEXT ????? FORMTEXT ?????(c) Guidance:Able to manage his/her own needPersons providing support cue to brush teethPersons providing support assist to clean teeth/denturesMedical/physical symptoms interfere with performing taskAware of hygiene needsBehavioral health challenges Other FORMTEXT ????? FORMTEXT ?????#9 Notes:10. General Hygiene-skip under 5yo: (a) General Hygiene: _________________________________________________________________________(b) Preferences:Assistance after eatingAssistance during morning routineAssistance before bedtimeElectric razorPrefers a female support PersonPrefers a male support personOther FORMTEXT ????? FORMTEXT ?????(c) Guidance:Able to manage his/her own need Support person applies the individuals’ deodorant Support person combs the individuals’ hair as needed Able to comb hair Able to wash face/handsMedical/physical symptoms interfere with performing taskNeeds reminders to use/change feminine hygiene productsIndividual knows how to use feminine hygiene productsPersons providing support shave the individual daily or as neededPersons providing support trim the individuals fingernails as neededAware of hygiene needsBehavioral health challenges Other FORMTEXT ????? FORMTEXT ?????#10 Notes:11. ADL Equipment: Scale: ?no need, ?needs doesn’t have, ?has doesn’t use, ?uses less than daily, ?uses daily. Mechanical lift _________________________________ Support person assists: ? Y ? N Prone Stander_________________________________ Support person assists: ? Y ? N Sidelyer______________________________________ Support person assists: ? Y ? N Body Jacket___________________________________ Support person assists: ? Y ? N #11 Notes:INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADLs) 12. Housework- skip under 12yo:(a) Housework: _____________________________________________________________________________ _____________________________________________(b) Preferences:Likes a neat houseWants items left where they arePrefers others to completeOther: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????(c) Guidance:Able to sweepAllergies to dust, pollen, etc. Behavioral health challenges Individual can do dishesIndividual can instruct support personIndividual can take out garbage Individual can wash windows Individual can make or change beddingIndividual can see when surfaces need cleaning Persons providing support change/wash linens weeklySupport person cue the individual to perform tasksMedical/physical symptoms interfere with performing taskPersons providing support dust/vacuum as needed Individual has chemical sensitivitiesPersons providing support mow lawn as needed Persons providing support shovel snow as needed Persons providing support sweep/mop floors as needed Persons providing support take out garbageOther: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????#12 Notes:13. Meal Preparation- skip under 12yo:(a) Make a light meal: _______________________________________________________________________ (b) Preferences:Bland diet Casein free dietFoods from my culture Fresh fruits and vegetables Gluten free dietHalal dietHome-cooked meals Home delivered meals Kosher diet Smaller meals, more than three times per dayLarge portions Other religious/ethnic foods Salt-free foodsSmall portions Sugar-free foods Vegetarian diet Vegan dietOther therapeutic diet: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????(c) Guidance:Individual assists with meal preparationBehavioral health challenges Individual can prepare food with cueing Individual can use the microwave Individual can cut/peel/chopIndividual can plan meals Individual directs support person to prepare meal Individual needs assistance when using kitchenMedical/physical symptoms interfere with performing taskIndividual knows how to cook Individual has food allergies Individual has accessible kitchenIndividual keeps spoiled food Persons providing support label/organize food productsIndividual leaves burners on Individual makes appropriate meal choices Persons providing support make food accessible to the individual Persons providing support prepare all meals Persons providing support prepare meals for individual to reheat Individual has special diet Work out a menu with individualOther: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? #13 Notes:14. Laundry- skip under 12yo: (a) Laundry: ___________________________________ _____________________________________________(b) Preferences:Prefers to fold certain items, describe: _______________________________________Prefers others to completeWants items left where they areOther: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????(c) Guidance:certain detergents or soaps Behavioral health challenges Individual can fold clothesIndividual can instruct support personIndividual can operate washer/dryerPersons providing support cue the individual to perform tasksMedical/physical symptoms interfere with performing task#14 Notes:15. Transportation:(a) Use Public Transportation- skip under 12yo: __________________________________________________(b) Car transfer- skip under 3yo: _______________________________________________________________ (c) Preferences:Accessible BusBikeTaxiRide sharing (e.g., Uber)Use own car, individual drivesUse own car, other person drivesOther: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????(d) Guidance:Persons providing support accompany person on bus/vanPersons providing support arrange medical transportation Behavioral health challenges Individual able to communicate with driversPersons providing support use own carPersons providing support drive individual to appointmentsHas handicap parking sticker/licenseKnows bus routesPersons providing support make arrangements for accessible busPersons providing support take portable oxygen tank Persons providing support take wheelchair/walker Persons providing support assist with securing wheelchair in accessible vehicleMedical/physical symptoms interfere with performing task Individual needs orientation and mobility training for new routesIndividual able to arrange own transportationPersons providing support use supportive seatingSupport person assists the individual to use vest/harnessOther: _______#15 Notes:16. Money Management- skip under 12yo:(a) Money Management: ________________________ _____________________________________________(b) Preferences: None listed(c) Guidance:Able to budget income and expensesPersons providing support arrange credit counselingSupport person balances individuals’ checkbook monthlyBehavioral health challenges Can use EBT cardCan use debit cardCan write checks and pay billsCan see/read bills and account information Persons providing support contact POA regarding finance issuesSupport person contacts representative payee regarding financial issuesIndividual signs own checksMedical/physical symptoms interfere with performing taskHas a representative payeeHas direct depositHas guardian/POANeeds Power of Attorney (POA)Support person pays bills for the individualNeeds automatic payment plan set upNeeds assistive/adaptive equipment to see paperworkNeeds budget set upNeeds utility payment set upVulnerable to financial exploitationRelies on others to understand that money has valueOther: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????#16 Notes:17. Light Shopping- skip under 12yo:(a) Light Shopping: _____________________________ _____________________________________________(b) Preferences: Shop at a specific storeShop weeklySpecialty itemsUse couponsOther: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????(c) Guidance:Able to communicate with store personnelPersons providing support arrange to have groceries deliveredBehavioral health challenges Can carry small itemsCan navigate within the storeCan see/identify needed itemsCan carry heavy itemsCan reach itemsCan read labels Can shop onlineMedical/physical symptoms interfere with performing taskSupport person assists with comparison shoppingPersons providing support do all shopping for the individualSupport person guides individual within store, find/describe items Persons providing support help individual make shopping listPersons providing support read labels to the individualPersons providing support put items awayPersons providing support take the individual to storeOther: FORMTEXT ????? FORMTEXT ?????#17 Notes:Additional Notes:BEHAVIORSScale: ?no history (5-year limit), ?has history no concern, ?has history has concern, ? no history has concern, ? yes-present (Pro-active supports here)Describe presenting behaviors18. Injurious to self: _____________________________ _____________________________________________19. Aggressive or Combative: _____________________ _____________________________________________20. Injurious to Animals: ______________________________________________________________________21. Aggressive Towards Others: ___________________ _____________________________________________22. Socially Unacceptable Behavior: ________________ _____________________________________________23. Sexual Aggression/Assault: ____________________ _____________________________________________24. Property Destruction: ________________________ _____________________________________________25. Leaving Supervised Area: _____________________ _____________________________________________ 26. Pica: _____________________________________ _____________________________________________27. Difficulties Regulating Emotions: ____________________________________________________________28. Refusing ADL/IADL and Medical Care: ___________ _____________________________________________29. Rapid Ingestion of Foods or Liquids: ____________ _____________________________________________30. Withdrawal: _______________________________ _____________________________________________31. Intrusiveness: ___________________________________________________________________________32. Susceptibility to Victimization: ______________________________________________________________33. Legal Involvement: _______________________________________________________________________34. Other Behavior: ____________________________ __________________________________________________________________________________________35. Blank Field36. Intervention frequency: Scale: ?None ?<1xmo ?1xmo ?>1xmo ?1-3xwk ?4+xwk, but <daily ?<5xday ?>5xday(a) Cueing: ____________________________________(b) Proactive Strategies/Physical Prompts: _______________________________________________________(c) Safeguarding interventions (AKA PPIs): _______________________________________________________37. Other behavior items:(a) Is a court mandated restriction currently in place against the individual: ? Y ? NType/Reason/Order date: __________________________________________________________________________________________________________________(b) Does the individual have a current court mandated restriction in place against anyone: ? Y ? NType/Reason/Order date: __________________________________________________________________________________________________________________38. Substance Abuse Issues:(a) Is there a concern about abuse of substances, including alcohol, marijuana, prescription medication, or illegal drugs: ? Y ? N Type: ____________________________________________39. Positive Behavior Support Plan:(a) Has a Positive Behavior Support Plan (PBSP) been created for the individual: ? Y ? N (b) Is the PBSP currently being implemented by support persons: ? Y ? N (c) Does the PBSP implementation include documentation of the incidence of behavior: ? Y ? N (d) Does the PBSP include Safeguarding Interventions/PPIs: ? Y ? N (e) Does the individual’s PBSP include complex behavior support tools that must be developed or significantly altered by a support person one or more times per month: ? Y ? N (f) Has the individual required emergency services, crisis intervention services or protective services to address a dangerous behavior 2 or more times in the past 12 months: : ? Y ? N Behavior Notes:SAFETY40. Safety Awareness and Support- skip under 5 yo: (a) Does the individual have the judgment and/or physical ability to cope, make appropriate decisions, (e.g., selecting clothing appropriate for weather), and take action in a changing environment or a potentially harmful situation: ? Y ? N? Judgement/Decision making: ___________________? Physical Ability: ______________________________? Behavior Issue: ______________________________(b) Does the ind. need support to remain safe around traffic: ? Y ? N ____________________________________________________________________________(c) Does the ind. need support to evacuate when a fire or smoke alarm sounds: ? Y ? N ______________________________________________________________41. Environmental Safety:(a) Is the individual at risk of serious injury from household chemicals if the chemicals are not secured: ? Y ? N __________________________________________________________________________________(b) Are there currently conditions in the residence that may lead to injury or illness: ? Y ? N ___________________________________________________________(c) Is the individual at risk of eviction because of conditions within the residence: ? Y ? N _______________________________________________________42. Assessor’s Judgement about the Potential for Abuse, Neglect, and Exploitation: (a) Is this individual at significant risk, beyond the typical risk for an individual with I/DD, for neglect, abuse, or exploitation by another person: ? Y ? N __________________________________________________________________________________________(b) is this person at risk of self-neglect - skip under 18yo: ? Y ? NCheck all that apply: *alcohol/drugs *beh to self & harm/to others *dehydration/malnutrition *hygiene compromised *impairment: orient/judge/reason *Unable to manage funds. *unable to manage meds/med treatment *unsafe living conditions. *other_____________________________________________________________________________________(c) Has child welfare been involved on behalf of the individual -skip over 17yo: ? Y ? N ____________________________________________________________Safety Notes:MEDICAL43. General Medical Supports:(a) In the past 6 months, how many times has another person recommended that the individual seek medical attention for an issue that the individual was unaware of or unwilling to seek attention for- skip under 18yo: *None, *one, *two or three, *more than 3 __________ and why: *Ind. unaware of issue, *Ind. unwilling to seek attention for issue, *Other: ___________________________________________________________________(b) Does the individual currently experience a lack of access to medical care because of transportation, geographical, financial, cultural, or other non-behavioral reasons -skip under 18yo: ? Y ? N *Transportation, *Geographical, *Financial, *Cultural, Other: ________________________________________(c) Does the individual require documented daily monitoring of temperature, respiration, heart rate, and/or blood pressure according to a documented physician’s order: ? Y ? N(d) Is the individual able to report or describe pain and /or signs of illness and where it’s located: ? Y ? N _____________________________________________(e) Does the individual need assistance to make and/or keep medical appointments- skip under 18yo: ? Y ? N_____________________________________________44. Conditions and Diagnoses:Health conditions/Specific Diagnoses: (has condition (HC), affects functioning (AF), receiving treatment (RT), f/u needed (F/U)) HC AF RT F/U(a) Chronic Chest Congestion: ? ? ? ? (b) Dysphagia: ? ? ? ?(c) GERD: ? ? ? ?(d) Persistent cough: ? ? ? ?(e) Pneumonia: ? ? ? ?(f) Rattling when breathing: ? ? ? ?Additional Feedback: ____________________________45. Seizure & Diabetes (a) Does the individual have a diagnosis of seizures or epilepsy or has the individual had a seizure within the past five (5) years: ? Y ? N(b) Indicate all items that apply to the individual: Currently takes medication to control seizures: ? Y ? NRequired a PRN medication (such as Ativan or Diastat) two or more times per month, at the time of the seizure to stop a seizure in the past year: ? Y ? NHas taken medication to control seizures in the past year: ? Y ? N Has had a seizure in the past year: ? Y ? NHas had seizures that required emergency medical attention in the last three years: ? Y ? N Uses a vagus nerve stimulator (VNS) two or more times per month: ? Y ? N (c) Does the individual require support to prevent injury during or prior to a seizure episode: ? Y ? N Describe support needed: _____________________________________________________________________(d) Does the individual have a diagnosis of ?diabetes or ?pre-diabetes: ? Y ? N (e) Does the individual use a diabetic insulin pump: ? Y ? N(f) Does the individual’s diabetes management include administration of sliding scale insulin: ? Y ? N___Administered by the individual without in-person assistance___Administered by the individual with in-person assistance___Administered by support person(g) Mechanisms to manage diabetes: Currently used:____Therapeutic Diet____Exercise____Blood glucose testing____Insulin administration____Other_________________________________Advisable, but additional support needed to implement____Therapeutic Diet____Exercise____Blood glucose testing____Insulin administration____Other_________________________________Advisable, but individual chooses not to implement____Therapeutic Diet____Exercise____Blood glucose testing____Insulin administration____Other_________________________________ ____No mechanisms advisable 46. Treatments and Therapies: (a) Is the individual currently receiving or currently needs any special treatments, such as pacemaker, bowel program, ostomy care, oxygen therapy, feeding tube, or dialysis: ? Y ? N(b) Treatments and Monitoring:Indicate current need: Has never needed Does not currently need, has needed in the pastNeeds but does not receiveReceives less than weeklyReceives weekly, <5 days per weekReceives weekly, 5 or more days per weekReceives dailyReceives 5 or more times per day(SP) Indicate if the Support Person performs the treatment(NO) Indicate if the Support Person requires training and oversight from a medical professional (such as nursing delegated tasks)Treatments/Monitoring/Therapy TypeNeed SP NO_________ ? ? Respiratory therapy _________ ? ? Chest percussion (including percussion vest)_________ ? ? Postural drainage_________ ? ? Nebulizer_________ ? ? Tracheal aerosol therapy_________ ? ? Oral suctioning that does not extend beyond the oral cavity_________ ? ? Airway suctioning_________ ? ? Tracheal suctioning_________ ? ? nasopharyngeal suctioning_________ ? ? Other suctioning_________ ? ? Tracheostomy care_________ ? ? Care for central line_________ ? ? Intravenous (IV) injections/infusions_________ ? ? Subcutaneous injections_________ ? ? Jejunostomy tube_________ ? ? Nasogastric or abdominal feeding tube (e.g., g-tube, NG tube)_________ ? ? Indwelling or suprapubic catheter monitoring_________ ? ? Insertion of catheter (intermittent catheterization)_________ ? ? CPAP/BiPAP_________ ? ? Mechanical ventilator other than CPAP/BiPAP_________ ? ? Oxygen therapy_________ ? ? Colostomy, urostomy, and/or other ostomy_________ ? ? Peritoneal dialysis_________ ? ? Hemodialysis_________ ? ? Active Cerebral shunt monitoring_________ ? ? Baclofen pump_________ ? ? Wound car, excluding stage III or IV ulcersNeed SP NO_________ ? ? Treatment for stage III or IV ulcers (full loss of skin and tissue, may extend into muscle or bone)_________ ? ? Behavioral health therapies, including mental health_________ ? ? Psychiatric therapies/services_________ ? ? Other: ___________________________ ? ? Other: ___________________________ ? ? Other: __________________47. Medication Management: (a) Individual currently takes prescription medications or routine over-the-counter medications recommended by a medical professional: ? Y ? N(b) Does the individual take medication known to cause dehydration: ? Y ? N(c) Oral meds skip under 18yo: ___________________(d) Inhalant/Mist meds skip under 18yo: ___________(e) Injectable meds skip under 18yo: ______________(f) Topical meds skip under 18yo: _________________(g) Suppository meds skip under 18yo: _____________(h) Meds thru tube skip under 18yo: _______________Medical Notes: Additional Assessment Notes: ................
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