Va Form 10-0415 - Va Geriatrics And Extended Care (Gec) Referral Page 2
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5VA Geriatrics and Extended Care (GEC) Referral con't
8. Additional Information
YES
NO
8.1 In the last 90 days, has the patient moved in with others or have others moved in with the patient?
8.2 Are there any hazards or other factors that make it difficult for the patient to enter or leave the home? Any environmental factor
e.g., environmental factors such as stairs, broken elevators, etc., that make it difficult to leave the home (do not count poor
lighting or loose rugs/carpet)
8.3 Does the patient or primary caregiver believe the patient would be better off in another living environment?
YES, Performed for 2 or more hours
8.4 In the last 7 days, did the patient engage in 2 or more hours of physical activity, e.g.,
walking, cleaning the house or exercising?
NO, not performed or less than 2 hours
YES, Occasionally alone, even if only for an hour
8.5 In the last 7 days, has the patient been left alone in the mornings or afternoons?
NO, Never or hardly ever
8.6 Does the veteran have a substitute (surrogate) decision-maker designated? (Check any that apply, include names when available)
Guardian
Durable Power of Attorney
Health Care
Fiduciary/Conservator
Financial
8.7 Has the patient completed an Advance Directive?
YES
NO
(If yes, please place copy in Medical Record or send with patient)
10. Basic Activities of Daily Living
9. Skilled Care
Code YES if the patient had ANY difficulty, required cueing or
Will the patient require these treatments after
supervision, or DID NOT do the task in the last 7 days
YES
referral?
Last 7
Days
9.1 CPAP/BiPap or Ventilator
In the last 7 days, has the patient required help OR supervision to
perform any of the following activities?
YES
NO
9.2 Oxygen
10.1 Bathing (tub bath, shower, or sponge)
9.3 Suctioning
9.4 Tracheostomy Care
10.1.1 Did the patient require physical assistance with bathing?
9.5 Ostomy Care (other than tracheostomy)
10.2 Dressing (lower and upper body)
9.6 Dysphagia Diet
10.3 Eating (taking in food by any method, including tube feedings)
9.7 Tube Feeding (any method)
10.4 Using the toilet (using toilet, urinal, bedpan-getting on and off,
cleaning self, managing devices used and adjusting clothes)
9.8 Parenteral Feeding
10.5 Moving around in bed (moving to and from lying position, turning
9.9 IV Infusions
side to side, repositioning)
9.10 Medications by Injection
10.6 Transfers (moving to/from bed, chair, wheelchair, standing)
9.11 Urinary Catheter Care
10.7 Moving around indoors (Answer yes even if with cane, walker, or
scooter - Answer NO if uses wheelchair OR did not get around
9.12 Dialysis - Center- based
10.8 If uses wheelchair, moving around chair (propelling and
9.13 Dialysis - Home -based
maneuvering) Code YES if the patient can maneuver wheelchair by
him/herself (even if it is a power chair)
9.14 Wound Care (other than pressure ulcer)
10.9 Do any of the answers above (10-1 - 10-7) indicate a recent (2-3
YES
NO
9.15 Pressure Ulcer Care
mos) change in functioning? Code yes if the patient's function has
significantly changed in the recent past
9.16
Check the stage of the worst pressure ulcer
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2
3
4
11. CONTINENCE
YES
NO
11.1 Is the patient incontinent of urine?
9.17 Frequent Nurse Observation (more than
1/week)
11.2 Is the patient incontinent of stool?
9.18 Physical, Speech, Occupational or
12. SKIN
YES
NO
Kinesiotherapy
12.1 Has the patient experienced any troubling skin problems like
9.19 Alcohol, Drug, or other substance abuse
burns, bruises, or itching in the last 30 days?
treatment
Additional comments pertinent
9.20 Other
to this page have been added
(specify)
PATIENT'S LAST NAME, FIRST NAME, MIDDLE INITIAL
SOCIAL SECURITY NO.
Page 2 of 5
VA FORM
10-0415
MAY 2006
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