Virginia Uniform Assessment Instrument at a glance
What it is: Virginia Uniform Assessment Instrument, Virginia Department of Social Services UAI Part A.
Who signs: Assessment Completed By: Assessor's Name, Signature, Agency/Provider Name, Provider #, Section(s) Completed.
The blank Virginia Uniform Assessment Instrument: print it and complete it by hand
How to fill out Virginia Uniform Assessment Instrument, box by box
Dates
Dates: Screen, Assessment, Reassessment.
Check all that apply
Services: No 0 Yes 1 (Check All Services That Apply)
Problems: No 0 Yes 1 (Check All Problems That Apply) Telephone Not Accessible.
Functional Status
Check only one block for each level of functioning.
Diagnoses and Medications
Total No. of Medications: If 0, skip to Sensory Function.
Enter Codes for 3 Major, Active Diagnoses: None00 DX1 DX2 DX3
Ongoing medical/nursing needs
Are there ongoing medical/nursing needs? No 0 Yes 1. If yes, describe ongoing medical/nursing needs: Evidence of medical instability. Need for observation/assessment to prevent destabilization. Complexity created by multiple medical conditions.
Why client's condition requires a physician, RN, or trained nurse's aide to oversee care on a daily basis.
Cognitive impairment score
Cognitive Function: Give the client 1 point for each correct response. "Note: Score of 14 or below implies cognitive impairment."
Alcohol, substances and tobacco
If the client has never used alcohol or other non-prescription, mood altering substances, skip to the tobacco question.
Abuse, neglect or exploitation
While completing the assessment, if you suspect abuse, neglect or exploitation, you are required by Virginia law, Section 63.1-55.3, to report this to the Department of Social Services, Adult Protective Services.
Informal caregiver
Does the client have an informal caregiver? No 0 (Skip to Section on Preferences)
Assessment Completed By
Assessment Completed By: Assessor's Name, Signature, Agency/Provider Name, Provider #, Section(s) Completed.
Sources
[1] Virginia Uniform Assessment Instrument (UAI) Part A, Virginia Department of Social Services (the Official source link on this page).