Individual Service Plan (Isp) For Individuals With Developmental Disabilities Living In The Community Template Page 12

ADVERTISEMENT

HEALTHCARE COORDINATION INFORMATION
COORDINATION INFORMATION
NAME OR SPECIFIC TITLE OF THE DESIGNATED HEALTHCARE COORDINATOR:
A healthcare coordinator must be designated for all individuals; if the individual has a Low e-CHAT acuity level, and
they are their own guardian, they may choose to designate themselves to do this independently, or another member of
the team may be designated. If the individual has a Moderate or High e-CHAT acuity level a team member other than
PHONE:
the individual must be designated to fulfill this role – assisting the individual to be involved to the maximum extent
possible. The Healthcare Coordinator is the designated individual on the team who arranges for and monitors health
care services for the individual. This includes scheduling appointments, follow-up recommendations and assuring that
blood work, preventative screening and diagnostic testing is done.
DOES THE INDIVIDUAL HAVE AN ADVANCED DIRECTIVE FOR MEDICAL CARE?
YES
NO
IF THE INDIVIDUAL HAS AN ADVANCED MEDICAL DIRECTIVE, WHERE IS IT LOCATED?
PHONE:
IF APPLICABLE, WHO IS THE SURROGATE HEALTH DECISION MAKER?
Note: A surrogate health decision maker is either a guardian with legal powers to make health decisions or the person
the individual has chosen to make health decisions in the event they become incapacitated.
DOES THE INDIVIDUAL WANT MORE INFORMATION ABOUT ADVANCED DIRECTIVES?
YES
NO
IF MORE INFORMATION IS DESIRED, WHO WILL ASSIST THE INDIVIDUAL?
BY WHEN?
Information about advanced directives can be obtained through the Health Decisions Resource Team. Contact
Continuum of Care for information at 1-877-684-5259.
MEDICATION DELIVERY
WHO COMPLETED THE MEDICATION ADMINISTRATION ASSESSMENT TOOL? A nurse must complete the
AGENCY:
Medication Administration Assessment Tool (MAAT) for all adults receiving community living, day habilitation,
employment services or private duty nursing services; for adults who do not receive any of these services and for
PHONE:
children it is assumed that the parent/guardian takes full responsibility for medication delivery and completion of the
tool is optional.
NAME:
DATE:
AFTER CONSIDERING THE RESULTS OF THE MAAT, WHAT RECOMMENDATIONS HAVE BEEN MADE TO THE IDT REGARDING MEDICATION
DELIVERY?
WHAT IS THE TEAM’S FINAL DETERMINATION?
SELF-ADMINISTRATION
SELF-ADMINISTRATION WITH PHYSICAL ASSISTANCE
ASSISTANCE BY STAFF
ADMINISTRATION BY LICENSED/CERTIFIED PERSONNEL
If more than one category applies, include the explanation in the rationale below
RATIONALE FOR DECISION:
RESPONSIBLE PARTY(IES) FOR FILLING AND REFILLING PRESCRIPTIONS:
CONTACT(S):
PHONE NUMBER(S):
RESPONSIBLE PARTY(IES) FOR UPDATING THE MEDICATION ADMINISTRATION RECORD:
CONTACT(S):
PHONE NUMBER(S):
NAME: ______ DOB: ____
EFFECTIVE DATE of ISP: ____
PAGE 12 OF 17
version 3/13

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business