VA Geriatrics and Extended Care (GEC) Referral con't
13. Patient Behaviors and Symptoms
Last 7
Days
In the last 7 days, has the patient exhibited any of the following?
YES
NO
I3.1 Wandering (moved with no rational purpose, seemingly oblivious to needs or safety)? Wandering is purposeless movement often
without regard to safety. Pacing up and down is NOT wandering.
I3.2 Verbally abusive behaviors (threatened, screamed at, or cursed at others)? Code if any such behavior occurred, regardless of
patient's intent.
I3.3 Physically abusive behaviors (hit, shoved, scratched or sexually abused others)? Code if any such behavior occurred, regardless
of patient's intent.
I3.4 Resisting care (resisted taking medications /injections, ADL assistance, eating, or changes in position)?
I3.5 Hallucinations or delusions? Hallucinations are sensory (auditory, visual, olfactory, tactile) experiences that are NOT real
Delusions are ideas or beliefs that are held even though there is no evidence to support them or evidence that shows them to be
false.
14. Cognitive Status
YES, Patient consistently made reasonable decisions without difficulty
14.1 In the last 7 days was the patient able, without difficulty, to
make decisions that are reasonable about organizing the day,
such as when to get up, what meals to have or what clothes to
NO, Patient made decisions with difficulty OR did not make decisions
wear?
OR decisions were poor
YES, Patient's expression of information is understood, even if s/he has
I4.2 In the last 7 days, has the patient usually been able to make
difficulty in finding words or finishing thoughts
him/herself understood?
NO, Patient's expression of information is never (or rarely) understood
OR s/he is limited to making concrete requests
YES
NO
I4.3 In the last 90 days has the person become so agitated or disoriented that his safety was endangered or s/he required protection
by others as a result?
15. Prognosis
NO
YES
I5.1 In the last 7 days, has the person experienced a flare up of a recurrent or chronic health problem?
NO
YES
I5.2 Does the direct care staff (MD, rehab therapist) think the patient is capable of increased independence (in ADLs, IADLs, or
mobility)?
YES
NO
I5.3 Does the patient have a limited life expectancy (likely to be less than 6 months)?
16. Weight Bearing
I6.1 What is the patient's weight bearing status? Full
Partial
None
17. Diet
I7.1 Diet
Regular
Modified (Specify diet)
18. What equipment does the patient need? (Please place prosthetics requests)
18.9 Other (specify)
18.1 Hospital Bed
18.3 Trapeze
18.5 Cane
18.7 ADL equipment
18.2 Special mattress
18.4 Walker
18.6 Wheelchair
18.8 Orthotic or splint
19. What supplies does the patient need? (Please place orders for supplies)
19.9 Other (specify)
19.1 Catheters
19.3 Dressings
19.5 Tape
19.7 Ostomy supplies
19.2 Tubing
19.4 Wrappings
19.6 Glucose strips
19.8 Saline
PATIENT'S LAST NAME, FIRST NAME, MIDDLE INITIAL
SOCIAL SECURITY NO.
Page 3 of 5
VA FORM
10-0415
MAY 2006