Table 2: ACFI evidence summary ACFI evidence summary This must be attached to the evidence provided for each resident’s reconsideration to assist in organising the evidence you are providing for each reconsideration Note: the ACCR or NSAF must be included in the ACFI appraisal pack. Comments (provide details of attachments title, ACFI Checklist complete? Evidence provided section and/or page numbers) Mental and ACCR/NSAF Disorder/diagnosis Behavioural GP comprehensive medical assessment Source material Diagnosis Other practitioner assessment / notes Provide the title of additional documents that were seen at review Provide the title of documents that were NOT seen at review ACCR/NSAF Disorder/diagnosis Medical Diagnosis GP comprehensive medical assessment Source material Other practitioner assessment / notes Documentation seen Provide the title of additional documents at review that were seen at review Provide the title of documents that were New documentation NOT seen at review 1: Nutrition Nutrition Checklist Readiness to eat Contemporaneous Assessment (e.g. Registered Nurse, Allied Health) Eating Documentation seen Provide the title of documents that were at review seen at review Provide the title of documents that were New documentation NOT seen at review 2: Mobility Mobility Checklist Transfers Contemporaneous Assessment (e.g. Registered Nurse, Allied Health) Locomotion Documentation seen Provide the title of additional documents at review that were seen at review Provide the title of documents that were New documentation NOT seen at review 3: Hygiene Personal hygiene Checklist Dressing and Contemporaneous Assessment (e.g. undressing Registered Nurse, Allied Health) Washing and drying Grooming Documentation seen Provide the title of additional documents at review that were seen at review Provide the title of documents that were New documentation NOT seen at review 4: Toileting Toileting Checklist Use of toilet Contemporaneous Assessment (e.g. Registered Nurse, Allied Health) Toilet completion
Table 2: ACFI evidence summary ACFI evidence summary This must be attached to the evidence provided for each resident’s reconsideration to assist in organising the evidence you are providing for each reconsideration Note: the ACCR or NSAF must be included in the ACFI appraisal pack. ACFI Checklist complete? Evidence provided Comments (provide details of attachments title, section and/or page numbers) Mental and Behavioural Diagnosis Disorder/diagnosis Source material ACCR/NSAF GP comprehensive medical assessment Other practitioner assessment / notes Provide the title of additional documents that were seen at review Provide the title of documents that were NOT seen at review Medical Diagnosis Disorder/diagnosis Source material ACCR/NSAF GP comprehensive medical assessment Other practitioner assessment / notes Documentation seen at review Provide the title of additional documents that were seen at review New documentation Provide the title of documents that were NOT seen at review 1: Nutrition Nutrition Checklist Contemporaneous Assessment (e.g. Registered Nurse, Allied Health) Readiness to eat Eating Documentation seen at review Provide the title of documents that were seen at review New documentation Provide the title of documents that were NOT seen at review 2: Mobility Mobility Checklist Contemporaneous Assessment (e.g. Registered Nurse, Allied Health) Transfers Locomotion Documentation seen at review Provide the title of additional documents that were seen at review New documentation Provide the title of documents that were NOT seen at review 3: Hygiene Personal hygiene Checklist Contemporaneous Assessment (e.g. Registered Nurse, Allied Health) Dressing and undressing Washing and drying Grooming Documentation seen at review Provide the title of additional documents that were seen at review New documentation Provide the title of documents that were NOT seen at review 4: Toileting Toileting Checklist Contemporaneous Assessment (e.g. Registered Nurse, Allied Health) Use of toilet Toilet completion
acfi_request_for_reconsideration_template_2.docx