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Quality Of Life

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ASSIGN
483.20 Resident Assessments

001

F635

ORDERS - RECEIVED ON ADMISSION

 
 
 
 
 
 
 
 
 
 
 
 

002

F635

ADMISSION ORDERS - IMMEDIATE CARE

 
 
 
 
 
 
 
 
 
 
 
 

003

F635

ORDERS - SIGNED BY PHYSICIAN

 
 
 
 
 
 
 
 
 
 
 
 

004

F635

ADMISSION ORDERS - TRANSFER ORDERS

 
 
 
 
 
 
 
 
 
 
 
 

005

F636

RESIDENT ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

006

F636

COMPREHENSIVE ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

007

F636

IDENTIFICATION AND DEMOGRAPHIC INFORMATION

 
 
 
 
 
 
 
 
 
 
 
 

008

F636

IDENTIFICATION - LOCATION

 
 
 
 
 
 
 
 
 
 
 
 

009

F636

COMPREHENSIVE RESIDENT ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

010

F636

CUSTOMARY ROUTINE

 
 
 
 
 
 
 
 
 
 
 
 

011

F636

COGNITIVE PATTERNS

 
 
 
 
 
 
 
 
 
 
 
 

012

F636

SAFETY AWARENESS

 
 
 
 
 
 
 
 
 
 
 
 

013

F636

COMMUNICATION

 
 
 
 
 
 
 
 
 
 
 
 

014

F636

VISION

 
 
 
 
 
 
 
 
 
 
 
 

015

F636

MOOD AND BEHAVIOR PATTERNS

 
 
 
 
 
 
 
 
 
 
 
 

016

F636

PSYCHOLOGICAL WELL-BEING

 
 
 
 
 
 
 
 
 
 
 
 

017

F636

PHYSICAL FUNCTIONING - ADLs

 
 
 
 
 
 
 
 
 
 
 
 

018

F636

STRUCTURAL PROBLEMS

 
 
 
 
 
 
 
 
 
 
 
 

019

F636

CONTINENCE - BOWEL - BLADDER

 
 
 
 
 
 
 
 
 
 
 
 

020

F636

CONTINENCE - APPLIANCES

 
 
 
 
 
 
 
 
 
 
 
 

021

F636

DISEASE DIAGNOSES & HEALTH CONDITIONS

 
 
 
 
 
 
 
 
 
 
 
 

022

F636

DENTAL CONDITION

 
 
 
 
 
 
 
 
 
 
 
 

023

F636

DENTAL CONDITION STATUS

 
 
 
 
 
 
 
 
 
 
 
 

024

F636

NUTRITIONAL STATUS - INTAKE

 
 
 
 
 
 
 
 
 
 
 
 

025

F636

NUTRITION - WEIGHT - HEIGHT

 
 
 
 
 
 
 
 
 
 
 
 

026

F636

NUTRITIONAL STATUS

 
 
 
 
 
 
 
 
 
 
 
 

027

F636

SKIN CONDITION - PRESSURE SORE RISK

 
 
 
 
 
 
 
 
 
 
 
 

028

F636

ACTIVITY PURSUIT - ABILITY - DESIRE

 
 
 
 
 
 
 
 
 
 
 
 

029

F636

MEDICATIONS - OTC

 
 
 
 
 
 
 
 
 
 
 
 

030

F636

MEDICATIONS - PRESCRIPTION

 
 
 
 
 
 
 
 
 
 
 
 

031

F636

SPECIAL TREATMENTS AND PROCEDURES

 
 
 
 
 
 
 
 
 
 
 
 

032

F636

SPECIAL TREATMENTS

 
 
 
 
 
 
 
 
 
 
 
 

033

F636

3 MONTH DISCHARGE POTENTIAL

 
 
 
 
 
 
 
 
 
 
 
 

034

F636

MDS - TRIGGERED CARE AREAS

 
 
 
 
 
 
 
 
 
 
 
 

035

F636

DIRECT OBSERVATION - COMMUNICATION

 
 
 
 
 
 
 
 
 
 
 
 

036

F636

DOCUMENTATION PARTICIPATION

 
 
 
 
 
 
 
 
 
 
 
 

037

F636

COMMUNICATION

 
 
 
 
 
 
 
 
 
 
 
 

038

F636

DIRECT OBSERVATION

 
 
 
 
 
 
 
 
 
 
 
 

039

F636

COMMUNICATION

 
 
 
 
 
 
 
 
 
 
 
 

040

F636

OBSERVATION

 
 
 
 
 
 
 
 
 
 
 
 

041

F636

RESIDENT INTERVIEW

 
 
 
 
 
 
 
 
 
 
 
 

042

F636

LICENSED STAFF INTERVIEW

 
 
 
 
 
 
 
 
 
 
 
 

043

F636

COMMUNICATION - STAFF

 
 
 
 
 
 
 
 
 
 
 
 

044

F636

14 DAY ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

045

F636

ANNUAL ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

046

F637

SIGNIFICANT CHANGE

 
 
 
 
 
 
 
 
 
 
 
 

047

F638

QUARTERLY ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

048

F639

MDS - 15 MONTHS

 
 
 
 
 
 
 
 
 
 
 
 

049

F639

ASSESSMENT RETENTION

 
 
 
 
 
 
 
 
 
 
 
 

050

F639

MDS - USE OF RESULTS FOR COMPREHENSIVE CARE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

051

F639

SIGNATURE PAGE

 
 
 
 
 
 
 
 
 
 
 
 

052

F640

ENCODING DATA - ADMIT 7 DAY

 
 
 
 
 
 
 
 
 
 
 
 

053

F640

ENCODING DATA - ANNUAL 7 DAY

 
 
 
 
 
 
 
 
 
 
 
 

054

F640

ENCODING DATA - CHANGE 7 DAY

 
 
 
 
 
 
 
 
 
 
 
 

055

F640

ENCODING DATA - 1/4LY 7 DAY

 
 
 
 
 
 
 
 
 
 
 
 

056

F640

ENCODING DATA - D/C 7 DAY

 
 
 
 
 
 
 
 
 
 
 
 

057

F640

ENCODING DATA - ENTRY 7 DAY

 
 
 
 
 
 
 
 
 
 
 
 

058

F640

TRANSMITTING DATA - 7 DAYS

 
 
 
 
 
 
 
 
 
 
 
 

059

F640

TRANSMITTING DATA - COMPLIANCE

 
 
 
 
 
 
 
 
 
 
 
 

060

F640

MONTHLY TRANSMITTAL REQ'T - ADMISSION

 
 
 
 
 
 
 
 
 
 
 
 

061

F640

MONTHLY TRANSMITTAL REQ'T - ANNUAL

 
 
 
 
 
 
 
 
 
 
 
 

062

F640

MONTHLY TRANSMITTAL REQ'T - CHANGE

 
 
 
 
 
 
 
 
 
 
 
 

063

F640

MONTHLY TRANSMITTAL REQ'T - CORRECTION - FULL

 
 
 
 
 
 
 
 
 
 
 
 

064

F640

MONTHLY TRANSMITTAL REQ'T - CORRECTION - QUARTERLY

 
 
 
 
 
 
 
 
 
 
 
 

065

F640

MONTHLY TRANSMITTAL REQ'T - CORRECTION

 
 
 
 
 
 
 
 
 
 
 
 

066

F640

MONTHLY TRANSMITTAL REQ'T - 1/4LY

 
 
 
 
 
 
 
 
 
 
 
 

067

F640

MONTHLY TRANSMISSION - APPROVED FORMAT

 
 
 
 
 
 
 
 
 
 
 
 

068

F641

ASSESSMENT BY PROFESSIONALS

 
 
 
 
 
 
 
 
 
 
 
 

069

F641

RESIDENT PROBLEMS

 
 
 
 
 
 
 
 
 
 
 
 

070

F641

RESIDENT STATUS

 
 
 
 
 
 
 
 
 
 
 
 

071

F641

RESIDENT STRENGTHS

 
 
 
 
 
 
 
 
 
 
 
 

072

F641

PROFESSIONALS

 
 
 
 
 
 
 
 
 
 
 
 

073

F642

COORDINATION - RN

 
 
 
 
 
 
 
 
 
 
 
 

074

F642

CERTIFICATION - RN SIGNED

 
 
 
 
 
 
 
 
 
 
 
 

075

F642

CERTIFICATION - OTHERS SIGNED

 
 
 
 
 
 
 
 
 
 
 
 

076

F642

FALSIFICATION

 
 
 
 
 
 
 
 
 
 
 
 

077

F642

MDS - FALSIFICATION - CAUSES ANOTHER

 
 
 
 
 
 
 
 
 
 
 
 

078

F642

CLINICAL DISAGREEMENT

 
 
 
 
 
 
 
 
 
 
 
 

079

F644

COORDINATION - PASARR

 
 
 
 
 
 
 
 
 
 
 
 

080

F644

COORDINATION - PASARR - COMPLETION ON DAY OF ADMISSION

 
 
 
 
 
 
 
 
 
 
 
 

081

F644

COORDINATION - PASARR - LEVEL II

 
 
 
 
 
 
 
 
 
 
 
 

082

F644

COORDINATION - PASARR LEVEL II REFERRAL

 
 
 
 
 
 
 
 
 
 
 
 

083

F645

PASARR - PREADMISSION SCREENING - MENTAL DISORDER

 
 
 
 
 
 
 
 
 
 
 
 

084

F645

PASARR - SPECIALIZED SERVICES - MENTAL DISORDER

 
 
 
 
 
 
 
 
 
 
 
 

085

F645

PASRR - PREADMISSION SCREENING - INTELLECTUAL DISABILITY

 
 
 
 
 
 
 
 
 
 
 
 

086

F645

PASARR - SPECIALIZED SERVICES - INTELLECTUAL DISABILITY

 
 
 
 
 
 
 
 
 
 
 
 

087

F645

PREADMISSION SCREENING - NOT REQUIRED

 
 
 
 
 
 
 
 
 
 
 
 

088

F645

PASARR - ADMITTED AFTER INPATIENT CARE

 
 
 
 
 
 
 
 
 
 
 
 

089

F645

PASARR - SAME CARE AT HOSPITAL

 
 
 
 
 
 
 
 
 
 
 
 

090

F645

PASARR - PHYSICIAN CERTIFICATION

 
 
 
 
 
 
 
 
 
 
 
 

091

F646

PASARR - NOTIFY STATE MENTAL HEALTH/INTELLECTUAL DISABILITY AUTHORITY

 
 
 
 
 
 
 
 
 
 
 
 
483.21 Comprehensive Resident Centered Care Plans

092

F655

BASELINE CARE PLANS - 48 HOURS

 
 
 
 
 
 
 
 
 
 
 
 

093

F655

BASELINE CARE PLANS - INITIAL GOALS

 
 
 
 
 
 
 
 
 
 
 
 

094

F655

BASELINE CARE PLANS - PHYSICIAN'S ORDERS

 
 
 
 
 
 
 
 
 
 
 
 

095

F655

BASELINE CARE PLANS - DIETARY ORDERS

 
 
 
 
 
 
 
 
 
 
 
 

096

F655

BASELINE CARE PLANS - THERAPY SERVICES

 
 
 
 
 
 
 
 
 
 
 
 

097

F655

BASELINE CARE PLANS - SOCIAL SERVICES

 
 
 
 
 
 
 
 
 
 
 
 

098

F655

BASELINE CARE PLANS - PASARR

 
 
 
 
 
 
 
 
 
 
 
 

099

F655

COMPREHENSIVE CARE PLAN IN PLACE OF BASELINE CARE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

100

F655

COMPREHENSIVE CARE PLAN IN PLACE OF BASELINE CARE PLAN - MEET NEEDS

 
 
 
 
 
 
 
 
 
 
 
 

101

F655

SUMMARY - BASELINE CARE PLAN - INITIAL GOALS

 
 
 
 
 
 
 
 
 
 
 
 

102

F655

SUMMARY - BASELINE CARE PLAN - MEDICATION AND DIETARY INSTRUCTION

 
 
 
 
 
 
 
 
 
 
 
 

103

F655

SUMMARY - BASELINE CARE PLAN - SERVICES AND TREATMENTS

 
 
 
 
 
 
 
 
 
 
 
 

104

F655

SUMMARY - BASELINE CARE PLAN - UPDATED INFORMATION

 
 
 
 
 
 
 
 
 
 
 
 

105

F656

CARE PLANS - MEDICAL NEEDS

 
 
 
 
 
 
 
 
 
 
 
 

106

F656

CARE PLANS - NURSING NEEDS

 
 
 
 
 
 
 
 
 
 
 
 

107

F656

CARE PLANS - MENTAL - PSYCHOSOCIAL NEEDS

 
 
 
 
 
 
 
 
 
 
 
 

108

F656

CARE PLANS - PROFESSIONALS

 
 
 
 
 
 
 
 
 
 
 
 

109

F656

CARE PLANS - PHYSICAL WELL-BEING

 
 
 
 
 
 
 
 
 
 
 
 

110

F656

CARE PLANS - PSYCHSOCIAL WELL-BEING

 
 
 
 
 
 
 
 
 
 
 
 

111

F656

CARE PLANS - MENTAL WELL-BEING

 
 
 
 
 
 
 
 
 
 
 
 

112

F656

CARE PLANS - PROVIDED SERVICES

 
 
 
 
 
 
 
 
 
 
 
 

113

F656

CARE PLANS - PASARR RECOMMENDATIONS

 
 
 
 
 
 
 
 
 
 
 
 

114

F656

CARE PLANS - GOALS - OUTCOMES

 
 
 
 
 
 
 
 
 
 
 
 

115

F656

CARE PLANS - DISCHARGE PREFERENCE

 
 
 
 
 
 
 
 
 
 
 
 

116

F656

CARE PLANS - DISCHARGE PLANS

 
 
 
 
 
 
 
 
 
 
 
 

117

F657

COMPREHENSIVE CARE PLANS - 7 DAYS

 
 
 
 
 
 
 
 
 
 
 
 

118

F657

CARE PLAN - PREPARATION BY IDT

 
 
 
 
 
 
 
 
 
 
 
 

119

F657

CARE PLANS - RESIDENT AND REPRESENTATIVE NOT A PARTICIPANT

 
 
 
 
 
 
 
 
 
 
 
 

120

F657

CARE PLANS - IDT REVIEW AND UPDATE

 
 
 
 
 
 
 
 
 
 
 
 

121

F658

PROFESSIONAL STANDARDS

 
 
 
 
 
 
 
 
 
 
 
 

122

F658

PROFESSIONAL STANDARDS OF QUALITY - MD NOTIFICATION

 
 
 
 
 
 
 
 
 
 
 
 

123

F658

PROFESSIONAL STANDARD OF QUALITY - MD ORDERS - CARRIED OUT

 
 
 
 
 
 
 
 
 
 
 
 

124

F658

PROFESSIONAL STANDARDS OF QUALITY - PROMPT HOSPITALIZATION

 
 
 
 
 
 
 
 
 
 
 
 

125

F658

PROFESSIONAL STANDARDS OF QUALITY - CARE PLAN - NEEDS MET

 
 
 
 
 
 
 
 
 
 
 
 

126

F658

PROFESSIONAL STANDARDS OF QUALITY - MEDICATIONS AVAILABLE

 
 
 
 
 
 
 
 
 
 
 
 

127

F659

QUALIFIED PERSONS - CARE AND SERVICES

 
 
 
 
 
 
 
 
 
 
 
 

128

F659

QUALIFIED PERSONS - CARE & SERVICES PROVIDED BY OTHERS

 
 
 
 
 
 
 
 
 
 
 
 

129

F659

QUALIFIED PERSONS - EXPECTED OUTCOMES

 
 
 
 
 
 
 
 
 
 
 
 

130

F659

QUALIFIED PERSONS - LN - EXPECTED OUTCOMES - CARE PROVIDED

 
 
 
 
 
 
 
 
 
 
 
 

131

F659

QUALIFIED PERSONS - CULTURALLY COMPETENT AND TRAUMA INFORMED

 
 
 
 
 
 
 
 
 
 
 
 

132

F660

DISCHARGE PLANNING PROCESS - GOALS

 
 
 
 
 
 
 
 
 
 
 
 

133

F660

DISCHARGE PLANNING PROCESS - ACTIVE PARTNER

 
 
 
 
 
 
 
 
 
 
 
 

134

F660

DISCHARGE PLANNING PROCESS - READMISSIONS

 
 
 
 
 
 
 
 
 
 
 
 

135

F660

DISCHARGE PLANNING PROCESS - DISCHARGE NEEDS

 
 
 
 
 
 
 
 
 
 
 
 

136

F660

DISCHARGE PLANNING PROCESS - RE-EVALUATION

 
 
 
 
 
 
 
 
 
 
 
 

137

F660

DISCHARGE PLANNING PROCESS - IDT

 
 
 
 
 
 
 
 
 
 
 
 

138

F660

DISCHARGE PLANNING PROCESS - CAREGIVER SUPPORT

 
 
 
 
 
 
 
 
 
 
 
 

139

F660

DISCHARGE PLANNING PROCESS - RESIDENT INVOLVEMENT

 
 
 
 
 
 
 
 
 
 
 
 

140

F660

DISCHARGE PLANNING PROCESS - GOALS OF CARE

 
 
 
 
 
 
 
 
 
 
 
 

141

F660

DISCHARGE PLANNING PROCESS - RESIDENT INTEREST

 
 
 
 
 
 
 
 
 
 
 
 

142

F660

DISCHARGE PLANNING PROCESS - REFERRALS

 
 
 
 
 
 
 
 
 
 
 
 

143

F660

DISCHARGE PLANNING PROCESS - CARE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

144

F660

DISCHARGE PLANNING PROCESS - NOT FEASIBLE

 
 
 
 
 
 
 
 
 
 
 
 

145

F660

DISCHARGE PLANNING PROCESS - STANDARDIZED ASSESSMENT DATA

 
 
 
 
 
 
 
 
 
 
 
 

146

F660

DISCHARGE PLANNING PROCESS - EVALUATION OF DISCHARGE NEEDS

 
 
 
 
 
 
 
 
 
 
 
 

147

F661

DISCHARGE SUMMARY - RECAP OF STAY

 
 
 
 
 
 
 
 
 
 
 
 

148

F661

DISCHARGE SUMMARY - CONSENT

 
 
 
 
 
 
 
 
 
 
 
 

149

F661

DISCHARGE - RECONCILIATION OF MEDICATIONS

 
 
 
 
 
 
 
 
 
 
 
 

150

F661

DISCHARGE - PARTICIPATION AND CONSENT

 
 
 
 
 
 
 
 
 
 
 
 

151

F661

DISCHARGE - FOLLOW-UP CARE

 
 
 
 
 
 
 
 
 
 
 
 

152

F661

DISCHARGE SUMMARY - POST DISCHARGE PLAN OF CARE

 
 
 
 
 
 
 
 
 
 
 
 

153

F661

DISCHARGE - FOLLOW-UP CARE

 
 
 
 
 
 
 
 
 
 
 
 
483.24 Quality of Life

154

F661

DISCHARGE SUMMARY - PLAN OF CARE REQUIREMENTS

 
 
 
 
 
 
 
 
 
 
 
 

155

F675

CARE AND SERVICES TO ATTAIN OR MAINTAIN

 
 
 
 
 
 
 
 
 
 
 
 

156

F675

HIGHEST PRACTICABLE MENTAL WELL-BEING

 
 
 
 
 
 
 
 
 
 
 
 

157

F675

HIGHEST PSYCHOSOCIAL WELL-BEING

 
 
 
 
 
 
 
 
 
 
 
 

158

F675

HIGHEST PRACTICABLE PHYSICAL WELL BEING

 
 
 
 
 
 
 
 
 
 
 
 

159

F676

ADL DECLINE - UNAVOIDABLE

 
 
 
 
 
 
 
 
 
 
 
 

160

F676

ADLs - ABILITY - BATHING -GROOMING

 
 
 
 
 
 
 
 
 
 
 
 

161

F676

ADLs - BATHING - GROOMING - DRESSING

 
 
 
 
 
 
 
 
 
 
 
 

162

F676

ADLs - TRANSFER - AMBULATION

 
 
 
 
 
 
 
 
 
 
 
 

163

F676

ADLs - DIMINISHED ABILITIES

 
 
 
 
 
 
 
 
 
 
 
 

164

F676

ADLs - TOILET USE ABILITY

 
 
 
 
 
 
 
 
 
 
 
 

165

F676

ADLS - TOILETING - DIMINISHED ABILITIES

 
 
 
 
 
 
 
 
 
 
 
 

166

F676

ADLs - DIMINISHED EATING ABILITY

 
 
 
 
 
 
 
 
 
 
 
 

167

F676

ADLs - EATING ABILITY IDENTIFICATION

 
 
 
 
 
 
 
 
 
 
 
 

168

F676

ADLs - DIMINISHED SPEECH

 
 
 
 
 
 
 
 
 
 
 
 

169

F676

ADLs - DIMINISHED FUNCTIONAL COMMUNICATION SYSTEM

 
 
 
 
 
 
 
 
 
 
 
 

170

F676

ADLs - MAINTAIN - IMPROVE FUNCTIONAL ADLs

 
 
 
 
 
 
 
 
 
 
 
 

171

F676

ADLs - DIMINISHED LANGUAGE

 
 
 
 
 
 
 
 
 
 
 
 

172

F677

ADLs - MAINTAIN - IMPROVE GROOMING

 
 
 
 
 
 
 
 
 
 
 
 

173

F677

ADLs - MAINTAIN - IMPROVE ORAL CARE

 
 
 
 
 
 
 
 
 
 
 
 

174

F677

ADLs - MAINTAIN, IMPROVE NUTRITIONAL

 
 
 
 
 
 
 
 
 
 
 
 

175

F677

ADLs - MAINTAIN - IMPROVE PERSONAL CARE

 
 
 
 
 
 
 
 
 
 
 
 

176

F678

CPR

 
 
 
 
 
 
 
 
 
 
 
 

177

F678

CPR CERTIFIED STAFF

 
 
 
 
 
 
 
 
 
 
 
 

178

F679

ACTIVITY CALENDARS

 
 
 
 
 
 
 
 
 
 
 
 

179

F679

ENCOURAGEMENT TO ATTEND ACTIVITIES

 
 
 
 
 
 
 
 
 
 
 
 

180

F679

MOTIVATION

 
 
 
 
 
 
 
 
 
 
 
 

181

F679

ACTIVITY SUPPLIES

 
 
 
 
 
 
 
 
 
 
 
 

182

F679

SUPERVISION DURING ACTIVITIES

 
 
 
 
 
 
 
 
 
 
 
 

183

F679

ACTIVITIES CARE PLAN UPDATE

 
 
 
 
 
 
 
 
 
 
 
 

184

F679

ADAPTIVE TECHNIQUES

 
 
 
 
 
 
 
 
 
 
 
 

185

F679

LATECOMERS TO ACTIVITIES