No problem identified Chronic infections Stones Nephrostomy tube Other: Muscular-Skeletal No problem identified Limited range of motion Contractures Foot problems Bone/joint pain Missing limb Ortho devices (prosthetic) Other: Skin No problem identified Dry skin Fragile/tears Bruises easily Rashes/itchy skin Skin allergies Lotions/soaps/linens/sensitivities Open wounds Other: Neurology No problem identified Tremors Seizures Paralysis/paresthesia Other: Pain Management No problem identified Has pain Severity 1 10: – Describe location, duration, cause: **Please attach a copy of the current signed treatment plan from the facility. Instructions (1) Medical Complexity & Medical Care Needs in the box next to the corresponding descriptor or Nurse assessor ― Place an “X” medical care need required by the worker. ONC For this section, select: Basic, Intermediate, or Advanced/Special and mark in ― the scoring section. (2 4) Activities of Daily Living Part A, B, C ― ―
No problem identified Chronic infections Stones Nephrostomy tube Other: Muscular-Skeletal No problem identified Limited range of motion Contractures Foot problems Bone/joint pain Missing limb Ortho devices (prosthetic) Other: Skin No problem identified Dry skin Fragile/tears Bruises easily Rashes/itchy skin Skin allergies Lotions/soaps/linens/sensitivities Open wounds Other: Neurology No problem identified Tremors Seizures Paralysis/paresthesia Other: Pain Management No problem identified Has pain Severity 1 – 10: Describe location, duration, cause: **Please attach a copy of the current signed treatment plan from the facility. Instructions (1) Medical Complexity & Medical Care Needs Nurse assessor ― Place an “X” in the box next to the corresponding descriptor or medical care need required by the worker. ONC ― For this section, select: Basic, Intermediate, or Advanced/Special and mark in the scoring section. (2 ― 4) Activities of Daily Living ― Part A, B, C
F245-377-000.docx