The DSS-3122 form serves a pivotal role for individuals seeking admission into adult residential care programs, ensuring these settings are appropriate for their specific needs. These care facilities offer a 24-hour residential environment not equipped for constant medical supervision, making it crucial to identify those who require more intensive healthcare services elsewhere. This form is an essential tool facilitating the assessment of prospective residents' medical conditions, history, and their ability to engage in daily activities autonomously. By evaluating the individual’s primary diagnosis, recent surgeries, acute and chronic illnesses, and medication needs, healthcare providers can make informed decisions regarding the suitability of adult residential care. Besides medical history, the form probes into the individual's independence level in administering medications and their mobility status, which are critical in determining the need for support services. This comprehensive evaluation not only helps in crafting a tailored care plan to ensure the resident's health, safety, and well-being but also meets the requirements set by the New York State Department of Health for adult residential care programs. The inclusion and analysis of this information in the resident's record, subject to state health department review, underscores the form's significance in maintaining high standards of care and regulatory compliance.
| Question | Answer |
|---|---|
| Form Name | Dss 3122 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | dss 3122 form medical evaluation adult home, 3122 form adult home, substitute for dss form dss 3122 revised 6 96, medical evaluation 6 96 substitue for dss 3122 |
STATEMENT OF PURPOSE
Adult Residential Care Programs provide 24 hour residential care settings for dependent adults. They are not medical facilities. Persons in need of constant medical care and supervision should not be admitted or retained in an adult residential care facility because such a facility lacks the staff and expertise to provide needed services. Persons who, by reason of age and or physical and/or mental limitations, are in need of assistance with the basic activities of daily living, can be cared for in adult residential care settings.
The information solicited in this medical evaluation will assist you, the individual, and the operator of an adult residential care facility in determining the level of care needed to assure the health, safety and
MEDICAL EVALUATION
(Resident)
NAME
ADDRESS
SEX |
DATE OF BIRTH |
EXAMINATION DATE |
MF
SECTION I: MEDICAL HISTORY
PRIMARY DIAGNOSIS
RECENT SURGERY (type of procedure and date)
RECENT ACUTE ILLNESS (type and date)
CHRONIC ILLNESS, PHYSICAL OR MENTAL LIMITATIONS
SPECIAL DIET
WEIGHT (include opinion regarding overweight, etc.)
BLOOD PRESSURE
ACTIVITY RESTRICTIONS
WEIGHT BEARING (full, partial, none)
REQUIRED PERIODIC OR INTERMITTANT NURSING CARE, AND/OR MEDICAL EXAMINATIONS, DOCTORS’ VISITS, OR SKILLED OBSERVATION OF SYMPTOMS:
SECTION II: MEDICATIONS NEEDED
TYPE, FREQUENCY, AND DOSAGE
SECTION III: OBSERVATION OF INDIVIDUAL
yes |
no |
Is the individual capable of |
yes |
no |
Bedfast – Unable to transfer |
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Required medications? |
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yes |
no |
Ambulatory – Without assistance |
yes |
no |
Incontinent (describe) |
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yes |
no |
Ambulatory – With assistance |
yes |
no |
Habituated or addicted to alcohol or other substance |
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yes |
no |
Chairfast – Able to transfer |
yes |
no |
If yes, is the individual a danger to himself or others |
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yes |
no |
Chairfast – Unable to transfer |
yes |
no |
Free of communicable disease |
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yes |
no |
Bedfast – Able to transfer |
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SECTION IV:
In your opinion does the individual need the support and services available in and adult residential care setting? |
(please describe fully) |
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Does the individual require placement in a skilled nursing or health related facility? (give reasons) |
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PHYSICIANS SIGNATURE |
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DATE |
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