Ahca Form 3110 1023 PDF Details

Navigating the prerequisites for adult family-care homes becomes significantly more streamlined with the understanding of the AHCA 3110 1023 form, a comprehensive document designed for the assessment of residents’ health in these settings. This form meticulously records a wide array of essential health-related information, starting with basic identification and extending to detailed medical history, diagnoses, physical or sensory limitations, and cognitive or behavioral statuses. It goes further to chart out the individual’s requirements for nursing, treatment, or therapy services, alongside any special precautions that need to be observed. A critical section of the form evaluates the resident's degree of independence in daily activities, such as ambulation, bathing, dressing, toileting, eating, grooming, and transferring, indicating the level of supervision or assistance required. Additionally, the form inquires about the resident's capability to perform self-care tasks, their need for general oversight, dietary requirements, medication details, and specific health conditions or requirements that could influence their care plan. The form concludes with a professional’s assessment of whether the individual's needs can be adequately met in an adult family-care home and if unsupervised time is advisable. By providing a thorough framework for evaluating the suitability of prospective residents, the AHCA 3110 1023 form plays a pivotal role in ensuring that individuals are placed in environments that can best support their health and safety needs.

QuestionAnswer
Form NameAhca Form 3110 1023
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesahca assessment, ahca form 3110 1024, form 3110 1023, form health assessment care

Form Preview Example

RESIDENT HEALTH ASSESSMENT FOR ADULT FAMILY-CARE HOMES (AFCH)

NAME:

D.O.B.

 

KNOWN ALLERGIES:

HEIGHT:

WEIGHT:

 

 

 

 

HEALTH ASSESSMENT

 

Medical history and diagnoses:

Physical or sensory limitations:

Cognitive or behavioral status:

Nursing/treatment/therapy service requirements:

Special precautions:

ATo what extent does the individual need supervision or assistance with the following? Please check appropriate areas below.

AMBULATION:

BATHING:

DRESSING:

TOILETING:

__Independent

__Independent

__Independent

__Independent

__Needs Supervision

__Needs Supervision

__Needs Supervision

__Needs Supervision

__Needs Assistance

__Needs Assistance

__Needs Assistance

__Needs Assistance

__Needs Total Help

__Needs Total Help

__Needs Total Help

__Incontinence

 

 

 

__Catheter Care

EATING:

GROOMING:

TRANSFERRING:

__Ostomy Assistance

__Independent

__Independent

__Independent

 

__Needs Supervision

__Needs Supervision

__Needs Supervision

 

__Needs Assistance

__Needs Assistance

__Needs Assistance

 

__Tube Feeding

__Needs Total Help

__Needs Total Help

 

Comments (Use additional page if necessary):

BTo what extent is the individual able to perform other self-care tasks such as preparing meals, shopping, or making phone calls? Please check the appropriate box below.

Independent

 

Needs Supervision

Comments (Use additional page if necessary):

Needs Assistance

Needs Total Assistance

CTo what extent does the individual need general oversight such as observing the

individual’s well-being and whereabouts and reminding the individual of important tasks? Please check the appropriate box below.

Independent

 

Weekly Oversight

Comments (Use additional page if necessary):

Daily Oversight

Other: Please describe below.

AHCA Form 3110-1023 (AFCH-1110) 01/08

1

Rule 58A-14.0061, F.A.C.

DDoes the individual require special diet instructions? Please check the appropriate box below.

Regular

Diabetic Diet

No Added Salt

Low Fat

Low Cholesterol

Other: Please describe below:

EPlease list all current medications prescribed below (additional pages may be attached).

 

MEDICATION

DOSAGE

DIRECTIONS FOR

ROUTE

 

 

 

USE

 

1.

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

6.

 

 

 

 

 

 

 

 

 

Does the individual need help with medications? _____YES______NO. If yes, please describe:

FDoes the individual have any of the following conditions or requirements? Please check appropriate boxes below.

YES NO COMMENTS

A communicable disease which could be transmitted to other residents or staff?

Bedridden?

Any stage 2, 3, or 4 pressure sores?

Pose a danger to self or others?

Require 24-hour nursing care?

Require 24-hour psychiatric supervision?

GIn your professional opinion, can this individual’s needs be met in a residential facility (Adult Family Care Home) that is not a medical, nursing or psychiatric facility? ______YES______NO Comments (Use additional page if necessary):

HIn your professional opinion, based on this individual’s medical profile, can this individual be left without supervision at the adult family care home for up to two hours per twenty-four (24) hour period without compromising his or her health, safety, security or well-being?

______YES______NO Comments (Use additional page if necessary):

AHCA Form 3110-1023 (AFCH-1110) 01/08

2

Rule 58A-14.0061, F.A.C.

NAME OF EXAMINER (Please Print):

SIGNATURE OF EXAMINER:

MEDICAL LICENSE #:

ADDRESS OF EXAMINER:

TELEPHONE #:

TITLE OF EXAMINER (Please check the appropriate box:

DATE OF EXAMINATION:

MD

DO

ARNP

PA

PLEASE RETURN THE COMPLETED FORM TO:

AFCH PROVIDER NAME:

ADDRESS:

TELEPHONE #:

CONTACT PERSON:

AHCA Form 3110-1023 (AFCH-1110) 01/08

3

Rule 58A-14.0061, F.A.C.

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1. Start completing your form 3110 1023 with a group of major blank fields. Gather all of the required information and ensure not a single thing overlooked!

Writing section 1 of health assessment family care

2. Right after completing this step, head on to the next step and fill in all required particulars in these fields - AMBULATION Independent Needs, BATHING Independent Needs, TOILETING Independent Needs, DRESSING Independent Needs, B To what extent is the individual, meals shopping or making phone, Independent, Needs Supervision, Comments Use additional page if, Needs Assistance, Needs Total Assistance, and C To what extent does the.

AMBULATION Independent Needs, TOILETING Independent Needs, and BATHING Independent Needs inside health assessment family care

People often make errors when filling out AMBULATION Independent Needs in this section. Make sure you review everything you type in right here.

3. The following section focuses on C To what extent does the, Independent, Weekly Oversight, Daily Oversight, Other Please describe below, Comments Use additional page if, and AHCA Form AFCH Rule A FAC - fill in all these blanks.

health assessment family care writing process explained (stage 3)

4. Completing below , Regular, Diabetic, No Added, Diet, Salt, Low Fat, Low Cholesterol, Other Please describe, below, E Please list all current, MEDICATION, DOSAGE, DIRECTIONS FOR, and ROUTE is essential in this fourth step - be certain to take the time and take a close look at every field!

health assessment family care writing process outlined (step 4)

5. The final stage to finish this PDF form is pivotal. Make certain to fill in the necessary blanks, like A communicable disease which could, YES NO COMMENTS, In your professional opinion can, and In your professional opinion based, before using the file. Otherwise, it may result in an incomplete and possibly invalid document!

Step no. 5 in filling out health assessment family care

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