Dhsr Ac 4207 Form – Fill Out and Use This PDF

DHSR/AC 4207 (Rev. 09/11) NCDHHS

RESIDENT REGISTER

The following resident information is to be completed and signed by the Administrator or Supervisor-in-Charge/Administrator-in- Charge and the resident or his/her responsible person within 72 hours of admission and kept in the resident’s record in the home. Write “N/A” if the requested information is not applicable to the resident.

NAME OF HOME/FACILITY ________________________________________________________________________________

A.IDENTIFYING INFORMATION

1.NAME______________________________________________________________________________________________

(first)

(middle)

(last)

(what resident prefers to be called)

2.DATE OF ADMISSION________________________________________

(month)

(day)

(year)

3.FORMER ADDRESS _________________________________________________COUNTY:________________________

ADMITTED FROM:	 Own Residence	 Another’s Residence
	A facility:_______________________________________________________________________
	(Name)	(Address)
	Other:__________________________________________________________________________

4.BIRTHDATE__________________ BIRTHPLACE______________________ SS#_______________________________

5.MEDICARE #_________________MEDICAID #__________________OTHER INSURANCE #’S____________________

6. MARITAL STATUS  Single  Married  Partnered  Widowed  Divorced  Separated

7.GENDER  Female  Male

8.	RACE	 Caucasian	 African-American		 Native-American	 Hispanic		 Other________________
9.	FAMILY	Father____________________________________ Mother________________________________________
						(include maiden name)
	CHILDREN__________________________________________________________________________________________
	SIBLINGS___________________________________________________________________________________________
	SPOUSE/PARTNER (Address if applicable)________________________________________________________________
10.	RESPONSIBLE PERSON (if applicable)___________________________________________________________________
						Phone (	)
	Address______________________________________________________________________________________________
	Nature of Responsibility:		 Guardian	 Power of Attorney  Payee
11.	CONTACT PERSON (If responsible person is not designated)__________________________________________________
						Phone (	)
	Address:_____________________________________________________________________________________________

12.PERSON IDENTIFIED BY THE RESIDENT TO RECEIVE A COPY OF THE DISCHARGE NOTICE

Name _______________________________________________________________________________________________

Phone ( )

Address______________________________________________________________________________________________

B.RESOURCE INFORMATION

1.ATTENDING PHYSICIAN:_____________________________________________________________________________

Address______________________________________________________________________________________________

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DHSR/AC 4207 (Rev. 09/11) NCDHHS

2.PREVIOUS PHYSICIAN_______________________________________________________________________________

Phone ( )

Address______________________________________________________________________________________________

PLANS MADE FOR PAYMENT OF: Personal Needs________________________________________________________

Other________________________________________________________________________________________________

C.PERSONAL INFORMATION

1. ASSISTANCE REQUIRED FOR: (Check all that apply)

 Dressing	 Correspondence	 Mouth Care
 Bathing	 Getting In/Out of Bed	 Feeding
 Nail Care	 Toileting	 Positioning/Turning
 Shaving	 Hair/Grooming	 Scheduling Appointments
 Ambulation	 Skin Care	 Orientation to Time and Place

(Other)_____________________________________________________________________________________

If different from information contained on the FL-2, home must contact resident’s physician for clarification.

2. MEMORY:

 Adequate

 Forgetful – Needs Reminders  Significant Loss – Must Be Directed

3.SPECIAL AIDS: (Check all that apply)

 Walker	 Hearing Aid			 Wheelchair
 Eyeglasses	 Dentures (Type)______________			 Other____________________________
4. PERSONAL HABITS:	 Smoking	 Alcohol	 Other___________________________________________

5.KNOWN ALLERGIES OR SUBSTANCES NOT TO BE ADMINISTERED (Drug, Food, or Otherwise):

6.FOOD PREFERENCES: If special diet, please describe:_______________________________________________________

____________________________________________________________________________________________________

FAVORITES

LEAST FAVORITES

Vegetable

Fruit

Meats

Meat Substitutes

Cereals and Breads

Milk or Buttermilk

Other Beverages

7.COMMUNITY INVOLVEMENT

a. FAITH COMMUNITY___________________________________ PASTOR___________________________________

Phone ( )

Address__________________________________________________________________________________________

b.CLUB, GROUP OR ORGANIZATIONAL MEMBERSHIPS_______________________________________________

c.SPECIAL SKILLS OR TALENTS_____________________________________________________________________

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DHSR/AC 4207 (Rev. 09/11) NCDHHS

d.PAST WORK AND VOLUNTEER SERVICE___________________________________________________________

e.HOBBIES________________________________________________________________________________________

f.ACTIVITY INTERESTS: (Review Listing of Suggested Activities with resident).

Favorites

Games

Music

Exercises

Outdoor Activity

Crafts

Outings

Social Activity

Work Type/Volunteer Activity

Intellectual Activity

g.ACTIVITIES STRONGLY DISLIKED OR TO BE AVOIDED:_____________________________________________

_________________________________________________________________________________________________

If there is a question about a resident’s ability to participate in an activity, the home must obtain a statement from the resident’s physician regarding the resident’s capabilities.

D.REQUEST FOR ASSISTANCE

Below are some areas in which the home can assist a resident upon the request of the resident or his/her responsible person. The administrator or supervisor-in-charge/administrator-in-charge must explain and complete each statement with the resident or his/her responsible person. The resident or his/her responsible person may subsequently change his/her mind and make a new request in writing at any time using Section H or some other notice. An equivalent signed record can be substituted for Section D.

1.I, as resident or the resident’s responsible person, request that pertinent information be secured from the facility from which I just left. Signature:________________________________________________________________________

2.I, as resident or the resident’s Legal guardian/payee, request that the management of this home handle my personal funds. I understand that the funds are available for my use during regular office hours and that I have the right to examine my account or to withdraw this request at any time. Signature:_____________________________________

3.I, as resident or the resident’s responsible person, request the use of lockable space for the security of personal valuables. I understand that I am entitled to one key at no charge and this space is accessible only to me and the administrator or supervisor-in-charge. Signature:_______________________________________________________

4.I, as resident or the resident’s responsible person, request that the management of this home –

a.Open my personal mail in my presence to read and explain the contents to me; and

b.Assist in handling my mail that pertains to my financial or medical affairs.

Signature:______________________________________________________________________________________

E.RECEIPT OF MATERIALS

I, as resident or the resident’s responsible person, acknowledge receipt of the following information which the management of the home reviewed with me:

Home’s resident contract specifying rates for the resident services and accommodations;

House Rules which include policies on refunds, smoking, alcohol consumption, visitation, and reasons for discharge;

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DHSR/AC 4207 (Rev. 09/11) NCDHHS

Declaration of Residents’ Rights;

Home’s grievance procedures for residents to present complaints and make suggestions as to the home’s policies and services; and

Home’s willingness to comply with Title VI of Civil Rights Act.

Other:_________________________________________________________________________________________

______________________________________________________________________________________________

Signature______________________________________

F.SIGNATURES

The resident or his/her responsible person should be asked to sign this form only after Sections A-E have been completed. The administrator or supervisor-in-charge/administrator-in-charge is to review this form with the resident or his/her responsible person at least once a year and revise it as needed using Section H. Section G is to be completed at the time the resident is discharged or transfers from the facility.

(Resident or Resident’s Responsible Person)	(Date)
(Administrator or Supervisor-in-Charge/Administrator-in-Charge)	(Date)

G.DISCHARGE/TRANSFER INFORMATION

1. NOTICE OF DISCHARGE/TRANSFER___________________________________________________________________

	(Month)	(Day)	(Year)
2. INITIATED BY:  Administrator	 Other_________________________________________________________

Reason(s)_______________________________________________________________________________________

3.DATE OF DISCHARGE/TRANSFER_____________________________________________________________________

			(Month)	(Day)	(Year)
	To:	 Own Residence	 Another’s Residence (Name)____________________________________________
		 A Facility	 Other_______________________________________________________________
4.				Phone (	)
	NEW ADDRESS______________________________________________________________________________________
5.	COPY OF THE DISCHARGE NOTICE HAS BEEN GIVEN TO THE PERSON IDENTIFIED BY THE RESIDENT IN
	SECTION A, #12 OF THIS FORM AS REQUIRED BY GENERAL STATUTE 131D-4.8?				 Yes (required)

I acknowledge the above information to be complete and accurate.

(Resident or Resident’s Responsible Person)	(Date)
(Administrator or Supervisor-in-Charge/Administrator-in-Charge)	(Date)

H.REVIEW/REVISION

The space below may be used to revise the information contained on the form.

Changes:___________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

(Resident or Resident’s Responsible Person)	(Date)
(Administrator or Supervisor-in-Charge/Administrator –in-Charge)	(Date)

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