Form Personal Care PDF Details

The Adult Care Home Personal Care Physician Authorization and Care Plan is a comprehensive document designed to ensure that residents of adult care homes receive the personalized care they need and deserve. At the core of this form is the resident's health assessment, which evaluates everything from medication needs, mental health and social history, to the finer points of daily living assistance requirements. These include mobility, nutrition intake, skin care, and more. Critical to the form is the need for detailed communication between the care facility and the resident's physician, ensuring that all medical diagnoses and the necessary personal care services are accurately documented and authorized. Besides medical aspects, the form also touches on important areas such as the resident's ability to perform daily living activities (ADLs), which covers eating, toileting, and grooming, among others. Each task is carefully assessed to determine the level of assistance required, demonstrating a thorough planning process aimed at providing tailored care. This process not only ensures the resident's health and safety but also respects their dignity and independence as much as possible. The ultimate goal is to create a supportive environment where residents can maintain the highest quality of life.

QuestionAnswer
Form NameForm Personal Care
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namespersonal physician authorization, printable inservices for caregivers, care physician authorization, form personal care

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ADULT CARE HOME

PERSONAL CARE PHYSICIAN AUTHORIZATION AND CARE PLAN

Assessment Date ___/___/___

Reassessment Date ___/___/___

Significant Change___/___/___

RESIDENT INFORMATION

(Please Print or Type)

RESIDENT _________________________________________ SEX (M/F) ____ DOB ____/____/____ MEDICAID ID NO. __________________________

FACILITY ____________________________________________________________________________________________________________________________

ADDRESS ___________________________________________________________________________________________________________________________

___________________________________________________________________PHONE ___________________ PROVIDER NUMBER __________________

DATE OF MOST RECENT EXAMINATION BY RESIDENT’S PRIMARY CARE PHYSICIAN ______/______/______

ASSESSMENT

1. MEDICATIONS – Identify and report all medications, including non-prescription meds, that will continue upon admission:

Name

Dose

Frequency

Route

() If Self-Administered

2.MENTAL HEALTH AND SOCIAL HISTORY: (If checked, explain in “Social/Mental Health History” section)

Wandering

Injurious to:

 

 

Is the resident currently receiving Mental Health, DD, or

 

 

Substance Abuse Services (SAS)?

YES

NO

 

 

 

 

Verbally Abusive

Self

Others

Property

 

 

 

Physically Abusive

 

 

 

Has a referral been made?

YES

NO

Is the resident currently receiving

 

 

 

 

 

 

 

 

 

Resists care

medication(s) for mental illness/behavior?

If YES:

 

 

Suicidal

YES

NO

 

 

 

 

 

 

 

Date of Referral _________________

 

 

 

 

 

 

Homicidal

Is there a history of:

 

Name of Contact Person _____________________________

Disruptive Behavior/

Substance Abuse

 

Developmental Disabilities (DD)

 

 

 

 

Agency ______________________________________________

Socially Inappropriate

Mental Illness

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social/Mental Health History: ________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

DMA-3050-R

Resident __________________________________

3.AMBULATION/LOCOMOTION: No Problems Limited Ability Ambulatory w/ Aide or Device(s) Non-Ambulatory Device(s) Needed _______________________________________________________________________________________________________________

 

Has device(s):

Does not use

Needs repair or replacement

 

 

 

 

 

4.

UPPER EXTREMITIES:

No Problems

Limited Range of Motion

Limited Strength

Limited Eye-Hand Coordination

 

Specify affected joint(s) _________________________________________________________________

Right

Left

Bilateral

 

Other impairment, specify __________________________________________________________________________________________________

 

_______________________________________________________________________________________________________________________________

 

Device(s) Needed ____________________________________________ Has device(s):

Does not use

Needs repair or replacement

5.

NUTRITION:

Oral

Tube (Type) ______________________________________ Height __________________ Weight __________________

 

Dietary Restrictions: ___________________________________________________________________________________________________________

 

________________________________________________________________________________________________________________________________

 

________________________________________________________________________________________________________________________________

 

________________________________________________________________________________________________________________________________

 

Device(s) Needed _______________________________________________________________________________________________________________

 

Has device(s):

Does not use

Needs repair or replacement

 

 

 

 

 

6. RESPIRATION:

Normal

Well Established Tracheostomy

Oxygen

Device(s) Needed _____________________________________________ Has device(s):

Shortness of Breath

Does not use

Needs repair or replacement

7.SKIN: Normal Pressure Areas Decubiti Other _______________________________________________________________

Skin Care Needs ______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________

8.

BOWEL:

Normal

Occasional Incontinence (less than daily)

Daily Incontinence

 

Ostomy: Type ______________________________________________________________ Self-care:

9.

BLADDER:

 

Normal

Occasional Incontinence (less than daily)

Daily Incontinence

 

Catheter: Type _________________________________________________________________ Self-care:

10.

ORIENTATION:

Oriented

Sometimes Disoriented

Always Disoriented

YES

YES

NO

NO

11.

MEMORY:

Adequate

Forgetful – Needs Reminders

Significant Loss – Must Be Directed

12.

VISION:

Adequate for Daily Activities

 

Limited (Sees Large Objects)

Very Limited (Blind); Explain___________________

 

Uses:

Glasses

Contact Lens

Needs repair or replacement

 

 

Comments ___________________________________________________________________________________________________________________

 

______________________________________________________________________________________________________________________________

13.

HEARING:

Adequate for Daily Activities

Hears Loud Sounds/Voices

Very Limited (Deaf); Explain _________________

 

Uses Hearing Aid(s)

Needs repair or replacement

 

 

 

Comments ___________________________________________________________________________________________________________________

14. SPEECH/COMMUNICATION METHOD:

Normal

Slurred

Weak

Other Impediment

Gestures

Sign Language

Writing

Foreign Language Only ________________________

Assistive Device(s) (Type _____________________________________)

Has device(s): Does not use

No Speech

Other None

Needs repair or replacement

Resident _______________________________________

DMA-3050-R

CARE PLAN

15.IF THE ASSESSMENT INDICATES THE RESIDENT HAS MEDICALLY RELATED PERSONAL CARE NEEDS REQUIRING ASSISTANCE, SHOW THE PLAN FOR PROVIDING CARE. CHECK OFF THE DAYS OF THE WEEK EACH ADL TASK IS PERFORMED AND RATE EACH ADL TASK BASED ON THE FOLLOWING PERFORMANCE CODES: 0 - INDEPENDENT,

1 - SUPERVISION, 2 - LIMITED ASSISTANCE, 3 - EXTENSIVE ASSISTANCE, 4 - TOTALLY DEPENDENT. (PLEASE REFER TO

YOUR ADULT CARE HOME PROGRAM MANUAL FOR MORE DETAIL ON EACH PERFORMANCE CODE.)

ACTIVITIES OF DAILY LIVING (ADL)

 

 

 

WEDNESDAY

 

 

 

DESCRIBE THE SPECIFIC TYPE OF ASSISTANCE NEEDED BY THE RESIDENT AND

SUNDAY

MONDAY

TUESDAY

THURSDAY

FRIDAY

SATURDAY

PROVIDED BY STAFF, NEXT TO EACH ADL:

 

 

 

 

 

 

 

EATING

TOILETING

AMBULATION/LOCOMOTION

BATHING

DRESSING

GROOMING/PERSONAL HYGIENE

TRANSFERRING

OTHER: (Include Licensed Health Professional Support (LHPS) Personal Care Tasks, as listed in Rule 42C .3703, and any other special care needs)

PERFORMANCE CODE

ASSESSOR CERTIFICATION

I certify that I have completed the above assessment of the resident’s condition. I found the resident needs personal care services due to the resident’s medical condition. I have developed the care plan to meet those needs.

Resident/responsible party has received education on Medical Care Decisions and Advance Directives prior to admission.

__________________________________________

______________________________________________

____________________

Name

Signature

Date

PHYSICIAN AUTHORIZATION

I certify that the resident is under my care and has a medical diagnosis with associated physical/mental limitations warranting the provision of the personal care services in the above care plan.

The resident may take therapeutic leave as needed.

_________________________________________

_____________________________________________

_____________________

Name

Signature

Date

DMA-3050-R

INSTRUCTIONS FOR COMPLETING THE REVISED ADULT CARE HOME PERSONAL CARE PHYSICIAN AUTHORIZATION AND CARE PLAN (DMA-3050-R)

The block in the upper right hand corner of the form denotes the type of assessment that is completed: Include Assessment date, Reassessment date, or Significant Change. Refer to the glossary in the Adult Care Home Services manual for the definition of significant change.

RESIDENT INFORMATION: In the Resident Information area include the resident’s name as it appears on the blue Medicaid ID card. Complete all information.

DATE OF MOST RECENT EXAMINATION: Includes a yearly physical by the resident’s attending physician.

ASSESSMENT:

1.MEDICATIONS: List the name of each medication, include non-prescription meds that the resident will continue upon admission. Check appropriate box for self-administered.

2.MENTAL HEALTH AND SOCIAL HISTORY: Identify by checking the appropriate box. Review records from discharging facility to monitor if there was any indication about history of injury to self, property, or others. Include meds for mental illness/behavior, and include if there is a history of Mental Illness, Developmental Disabilities, or Substance Abuse.

Is the resident currently receiving Mental Health (MH), Developmental Disabilities (DD), or Substance Abuse Services (SAS)? If a referral has been made for an evaluation, indicate the date of referral, name of contact person at the agency, and the agency name.

Social/Mental Health History: Include any history that can be gathered from assessment by the resident, family, friends, etc. that provide information about the resident’s preferences, activities and living status. This is also an area that needs to identify any Mental Health history such as institutionalization, out patient, compliance history, police record, etc.

TOP OF SECOND PAGE: RESIDENT_________________: Place name as on Medicaid ID card in this blank.

3.AMBULATION/LOCOMOTION: Check applicable block and list devices needed.

4.UPPER EXTREMITIES: Check applicable box and list devices needed.

5.NUTRITION: Check appropriate box. Indicate height and weight. Include any restrictions to diet, i.e. NAS, soft, etc.

6.RESPIRATION: Check appropriate box. Indicate any devices needed.

7.SKIN: Check appropriate box. Explain in detail treatment necessary and include any MD orders for skin care.

8.BOWEL: Check appropriate box. Indicate if the resident is independent of activity. Explain what resident needs from staff.

9.BLADDER: Check appropriate box. Indicate if the resident is independent of activity. Explain what residents need from staff.

10.ORIENTATION: Check appropriate box.

11.MEMORY: Check appropriate box.

12.VISION: Check appropriate box. Expand on concerns in comments area.

13.HEARING: Check appropriate box. Expand on concerns in comments area.

14.SPEECH/COMMUNICATION METHOD: Check appropriate box.

TOP OF THIRD PAGE: RESIDENT__________________: Place name as on Medicaid ID card in this

blank.

CARE PLAN:

15.Refer to the Adult Care Home Services manual for more detail on Performance Codes.

ACTIVITIES OF DAILY LIVING: Include a description of the specific type of assistance provided by staff next to each ADL and code the activity in the Performance Code area. In Other, list any Licensed Health Professional Support tasks as well as any special care needs in this area.

ASSESSOR CERTIFICATION: Check box for Medical Care Decisions and Advance Directives education. Signature of assessor certifies that the care plan is developed based on assessment findings.

PHYSICIAN AUTHORIZATION: The form is forwarded to the attending physician. The physician’s authorization certifies that the individual is under the physician’s care and has a medical diagnosis that warrants the provision of personal care services as indicated in the care plan. The physician prints his/her name, signs, and dates the form. The physician also may indicate and provide standing orders for an individual to take therapeutic leave by checking the block.