Fillable Form Cl07352-3 - Care Provider Assessment (Page 2 of 3) in pdf

Form Cl07352-3 - Care Provider Assessment Page 2

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PATIENT CARE INFORMATION

Date of Admission/Date care began: ____________________________________________________________________

Date of Discharge/Date care ended: ____________________________________________________________________

Number of Days charged for

________________________________________________________

(services/room & board):

Charge Per Day: $ __________________________________________________________________________________

Please note that we require itemized bills statements for reimbursement.

Patient Diagnosis/Reason for Admission:

1. ________________________________________________________

2. ________________________________________________________

3. ________________________________________________________

Attending/Recommending Physician: ___________________________________________________________________

Contact Phone: ____________________________________________________________________________________

ACTIVITIES OF DAILY LIVING

Please review each activity of daily living and provide an objective assessment of the assistance provided to the patient by

checking the most appropriate response for each activity. Please describe specific needs/limitations in notes section below.

Rating Scale:

0 = Without assistance

1 = Supervised

2 = Hands-on assistance

3 = Completely dependent

Task Description:

1. Bathing

h 0

h 1

h 2

h 3

2. Dressing

h 0

h 1

h 2

h 3

3. Eating/Feeding h 0

h 1

h 2

h 3

4. Toileting

h 0

h 1

h 2

h 3

5. Transferring

h 0

h 1

h 2

h 3

6. Continence

h 0

h 1

h 2

h 3

NOTES: __________________________________________________________________________________________

_________________________________________________________________________________________________

__________________________________________________________________________

COGNITIVE ASSESSMENT

Is a cognitive deficit present?

h No

h Yes If yes, please answer the following questions.

Level of cognitive deficit?

h Mild

h Moderate

h Severe

Describe any supervision required: _____________________________________________________________________

_________________________________________________________________________________________________

Are there any other issues arising from the cognitive impairment? ____________________________________________

_________________________________________________________________________________________________

Page 2 of 3

CL07352-3

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Form Cl07352-3 - Care Provider Assessment Page 2

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