Assessment after making the desired changes on the individual’s Health Care Record and finalizing the modified record. Information on the Health & Dental Assessment pulled from the Health Care Record Prompt number Prompt Description on the Health & Dental HCR Details on Assessment H&D 1 Individual’s Name Basic Information Screen 2 Date of Birth Basic Information Screen Current Medical Problem and Diagnoses 3 Height Screen Field – ‘Height’ Current Medical Problem and Diagnoses 4 Date Height Recorded Screen Field Height Recorded’ – ‘Date Current Medical Problem and Diagnoses 5 Weight (lbs) Screen Field (lbs) – ‘Weight Current Medical Problem and Diagnoses Screen 6 Date Weight Recorded Field Weight Recorded – ‘Date (MM/DD/YYYY format) Identify any current medical problems, diagnoses, treatments and medications: (All diagnoses must be supported by Current Medical Problem and Diagnoses documentation from a licensed and Screen qualified medical and/or mental health Field - Name’ ‘Medication 7 professional. DO NOT include HIV diagnosis and medications used to treat Medications List Screen HIV. Attach any relevant protocols for Prescription’ – ‘Reason including but not limited to Seizure, Dining, PICA.) Functional Status Screen 36 List all supportive device needs Devices’, Other, – ‘Supportive ‘If please specify’ Functional Status Screen Field - Communication from MEDITECH (Able to Communicate, Communication Difficulties/Uses Verbalizations, List all augmentative communication 38 Communication Difficulties/Uses needs Gestures, Not able to Communicate Needs, Unable to use Call Bell, Only Speaks/Understands a foreign language, Utilizes Communication Devices) Functional Status Screen Does the individual manage his/ her own 39 Field - Medication Administration from medications? MEDITECH (Independent/Self
Assessment after making the desired changes on the individual’s Health Care Record and finalizing the modified record. Information on the Health & Dental Assessment pulled from the Health Care Record Prompt number on H&D Prompt Description on the Health & Dental Assessment HCR Details 1 Individual’s Name Basic Information Screen 2 Date of Birth Basic Information Screen 3 Height Current Medical Problem and Diagnoses Screen Field – ‘Height’ 4 Date Height Recorded Current Medical Problem and Diagnoses Screen Field – ‘Date Height Recorded’ 5 Weight (lbs) Current Medical Problem and Diagnoses Screen Field – ‘Weight (lbs) 6 Date Weight Recorded Current Medical Problem and Diagnoses Screen Field – ‘Date Weight Recorded (MM/DD/YYYY format) 7 Identify any current medical problems, diagnoses, treatments and medications: (All diagnoses must be supported by documentation from a licensed and qualified medical and/or mental health professional. DO NOT include HIV diagnosis and medications used to treat HIV. Attach any relevant protocols including but not limited to Seizure, Dining, PICA.) Current Medical Problem and Diagnoses Screen Field - ‘Medication Name’ Medications List Screen – ‘Reason for Prescription’ 36 List all supportive device needs Functional Status Screen – ‘Supportive Devices’, ‘If Other, please specify’ 38 List all augmentative communication needs Functional Status Screen Field - Communication from MEDITECH (Able to Communicate, Communication Difficulties/Uses Verbalizations, Communication Difficulties/Uses Gestures, Not able to Communicate Needs, Unable to use Call Bell, Only Speaks/Understands a foreign language, Utilizes Communication Devices) 39 Does the individual manage his/ her own medications? Functional Status Screen Field - Medication Administration from MEDITECH (Independent/Self
isp-userguide-lesson4-feb2016.docx