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Primary Care Physician's Documentation

Participant Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone #

Gender

Male

Female

Authorization for Release of Medical Information

I hereby authorize my physician to release all applicable and relevant medical information to the Adult Day Health program for inclusion in the individual's records.

Signature of Participant

Date

MM slash DD slash YYYY

Staff Person

Date

MM slash DD slash YYYY

Medical History

Communicable Disease

PPD Placed on Date

PPD Read on Date

Result of TB

Result of chest X-Ray

If there is no TB record authorize chest X-Ray

Yes

Date of last physical examination

MM slash DD slash YYYY

Diagnosis

Dates of hospitalizations & condition treated for, in past 2 years

Functional Limitations

Date of Last Vaccinations

Vaccinations

Influenza

Pneumococcal

Tetanus

Current Medications

Medication

Dosage

Route

Frequency

Is this patient capable of self-administration of medications?

Yes

Is there any significant medical history and Allergies the ADHC needs to know?

Drug Allergies

Yes

If Yes please list

Food Allergies

Yes

If Yes please list

General Physical Condition

Good

Fair

Poor

Mental Status

Alert & Oriented

Confused

Lethargic

Memory Deficit

None

Mild

Moderate

Severe

Specific Problem

Speech

Normal

Aphasic

Incontinence - Bladder

Yes

Bowel

Yes

Vision

Normal

Eyeglasses

Contacts

Circulatory

Normal

Edema

Hearing

Normal

Hearing Aid R

Hearing Aid L

Respiratory

Normal

Dyspnea

Dentures

Lower

Upper

Cardiac

Normal

Arrhythmia

Pacemaker

Diet and Nutrition

Regular

No salt added (2500-4500 mg. NA)

Liberal diabetic (diet dessert, no sugar added)

Diabetic

Special considerations (chopped, ground, choking precautions etc.)

Other

Ambulation

Alone

Walker

Supervision

Wheelchair

Assist

Quad Cane

Cane

Paralysis

Vitals

Weight

Height

Temperature

Blood Pressure

Heart Rate

(AP)

Physical Findings

Head

Normal

Comments (if any)

Eyes

Normal

Comments (if any)

Ears

Normal

Comments (if any)

Nose

Normal

Comments (if any)

Throat

Normal

Comments (if any)

Skin

Normal

Comments (if any)

Respiratory

Normal

Comments (if any)

Abdomen

Normal

Comments (if any)

Cardiac

Normal

Comments (if any)

Vascular

Normal

Comments (if any)

Genito-Urinary (M)

Normal

Comments (if any)

Genito-Urinary (F)

Normal

Comments (if any)

Neuro-Psychiatric

Normal

Comments (if any)

Other

Normal

Comments (if any)

Previous Injuries, Falls, Fractures

Yes

Comments

Recommendations for therapy

Nursing Considerations

Blood pressure, pulse and weight will be measured at least monthly for all participants. If your patient needs more frequent monitoring and/or needs specialized nursing care, please specify:

Please indicate if RN needs to provide:

Finger stick: RBS/PRN

Assess LE edema: Weekly/PRN

SO2: Bi-W/PRN

Other

Physician Authorization

I hereby give my consent for this individual to attend the Adult Day Health Center.

Physician's signature

Address

Phone

Fax

Printed name

Date

MM slash DD slash YYYY

PatientName

DOB

New Diagnosis

ICD 10 Codes

SKILLED NURSING SERVICES PROVIDED AT ACTIVELIFE ADULT DAY CARE (Check all apply)

Skilled Observation

Cardiopulmonary Status

Cognitive/Mental Status

Neurological Status

Diabetes

Oxygen Saturation prn SOB

Blood Sugar Testing & Call Physician if BS 350

Assess and Monitor (Specify)

Administer enteral feeds

Monitor Vital Signs

Monthly or Other Frequency

Notify Physician if Specify Parameters

Monitor Weight

Monthly or Other Frequency

Assess and Monitor Nutritional Status

May administer medications at the ALADC

Monitor medications response, effectiveness, and side effects.

Behavioral Management

Therapeutic Activities

Additional Orders

Diabetes

Assess and Monitor (Specify)

Administer enteral feeds

Monitor Vital Signs

Monthly or Other Frequency

Notify Physician if Specify Parameters

Monitor Weight

Monthly or Other Frequency

Assess and Monitor Nutritional Status

Behavioral Management

Additional Orders

ADL RECOMMENDATION TO ACTIVELIFE ADULT DAY CARE

Ambulation

Independent

Cane

Walker

Wheelchair

Assist

Transfer

Independent

Supervision / Cueing

Assist

Dressing

Independent

Supervision / Cueing

Assist

Toileting

Independent

Supervision / Cueing

Assist

Bathing

Occasionally

Regularly

Eating

Supervision / Cueing

Assist

Diet Consistency

Regular

Mechanical Soft

Puree

Bathing

Occasionally

Regularly

ROUTINE MEDICATIONS ORDERS

Routine Medications Orders

Tylenol 325mg, 1-2 tablets po q4-6 prn pain

Ibuprofen 200mg po q4-6 prn pain

Maalox (x-strength) 10cc po q4hrs PRN GI distress

TUMS (750mg) 1-2tabs q6hrs prn heartburn

MOM 30cc po q12hrs PRN constipation

Kaopectate 30cc po q6hr PRN for diarrhea

Robitussin/diabetic tussin (if applies) 10ml q4hrs prn cough

Benadryl 25mg 1-2 tabs q4-6hrs prn hay fever, allergies

Epipen (1:1000 0.3ml) – SC for sings and symptoms (dyspnea, cyanosis, hypotension) of suspected anaphylaxic reaction.

Tylenol 325mg, 1-2 tablets po q4-6 prn pain

Ibuprofen 200mg po q4-6 prn pain

Maalox (x-strength) 10cc po q4hrs PRN GI distress

TUMS (750mg) 1-2tabs q6hrs prn heartburn

MOM 30cc po q12hrs PRN constipation

Kaopectate 30cc po q6hr PRN for diarrhea

Robitussin/diabetic tussin (if applies) 10ml q4hrs prn cough

Benadryl 25mg 1-2 tabs q4-6hrs prn hay fever, allergies

Epipen (1:1000 0.3ml) – SC for sings and symptoms (dyspnea, cyanosis, hypotension) of suspected anaphylaxic reaction.

Permitted to go to Field Trip

Yes

(Permitted to go to Field Trip)

Flu Vaccine: 0.5 cc IM, if requested (October to February, yearly).

Cut/Abrasions: Wash with normal saline solution. Apply antibiotic ointment. Cover with dressings if necessary.

DO YOU AGREE WITH THE ABOVE STANDING ORDERS?

Yes

*Please Attach a recent PHYSICAL EXAM, OFFICE VISIT NOTES & CURRENT MEDICATION LIST

Drop files here or

Max. file size: 256 MB.

Comment/OtherOrders

I hereby certify that this patient is appropriate for adult day health services.

Signature

Date

MM slash DD slash YYYY

Physician's Name (typed or printed)

Physician's Address

PCP Forms

Primary Care Physician's Documentation

Authorization for Release of Medical Information

Medical History

Current Medications

Diet and Nutrition

Vitals

Recommendations for therapy

Nursing Considerations

Physician Authorization

ADL RECOMMENDATION TO ACTIVELIFE ADULT DAY CARE

ROUTINE MEDICATIONS ORDERS

Email Address

Phone Number

Fax Number

Company Address

Activelife Adult Daycare Inc

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