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Georgia Department of Human Services COMMUNITY CARE SERVICES PROGRAM LEVEL OF CARE AND PLACEMENT INSTRUMENT

Section I - A. Identifying Information

2. Patient's Name (Last, First, Middle Initial):

1. CCSP ASSESSMENT TEAM NAME ADDRESS

                               Telephone:

3. Home Address:

4. Telephone Number;                                        5. County:                                              6. PSA:

7. Medicaid Number

8. Social Security Number

9. Mother's Maiden Name:

10. Sex

11. Age

12 Birthday

13. Race

14. Marital        Status

15. Type of Recommendation    1.         Initial    2.         Reassessment

16. Referral Source

This is to certify that the facility or attending physician is hereby authorized to provide the Georgia Department of Medical Assistance and the Department of Human Resources with necessary information including medical data.

17. Signed     ________________________________________________________________                                                                                   18. Date______________________________________

(Patient, Spouse, Parent or other Relative or Legal Representative)

B. Physician's Examination Report, Recommendation, and Nursing Care Needed

1. ICD

2. ICD

3. ICD

19. Diagnosis on Admission to Community Care (Hospital Transfer Record May Be Attached)                         20. Is Patient free of communicable disease? 1.  Primary ________________   2. Secondary _____________ 3. Other _________________                                          1 Yes      2 No

Medications (including OTC)

Diagnostic and Treatment Procedures

21. Name

Dosage

Route

Frequency

22 Type Frequency

23. COMMUNITY CARE SERVICES ORDERED :

24. Diet

25. Hours Out of Bed Per Day

26. Overall Cond

27 Restorative   Potential

28. Mental and Behavioral Status

 Regular

Intake         IV

Improving

 Good

Agitated              Noisy                       Dependent

 Diabetic

 Output         Bedfast

Stable

□  Fair

Confused              Nonresponsive        Independent

Formula

Catheter Care

 Fluctuating

Poor

Cooperative         Vacillating              Anxious

Low Sodium

Colostomy Care

Deteriotating

Questionable

Depressed            Violent                    Well Adjusted

Tube Feeding

Sterile Dressings

Critical

None

Forgetful              Wanders                  Disoriented

Other

Suctioning

Terminal

Alert                    Withdrawn               Inappropriate Reaction

29. Decubiti

30, Bowel

31. Bladder

32. Indicate Frequency

Per Week:

Physical Therapy

Occupational Therapy

Remotive Therapy

Reality Orientation

Speech Therapy

Bowel Bladder Retrain

Activities Program

Yes  No

 Continent  Occas, Incontinent

 Continent  Occas Incontinent

 Infected

Incontinent

Incontinent

 On Admission

Colostomy

Catheter

 Surgery Date

33

Record Appropriate Legend

IMPPAIRMENT                         

      ACTIVITIES            

OF DAILY

LIVING

1.  Severe

Ltd

Para-

Para-

1.

Dependent

Wheel-

Trans-

Ambu-

2.   Moderate

Sight

Hear        Speech

Motion

lysis

2.

Needs Asst,

Eats

Chair

fers

Bath

lation

Dressing

3.   Mild 4.   None

□        □   

   

 

3 4.

Independent Not App

 

34..  This patient's condition         could            could not be managed by38.  Physician’s Name (Print)        provision of           Community Care or    Home Health Services. 35.  I certify that this patient     requires     does not require the intermediate level39.  Physician’s Address (Print)        of care provided by a nursing facility. 36.  I certify that the attached plan of care addresses the client's needs for Community Care.40.  Date Signed By Physician             41.  Physician’s Licensure No.             42.   Physician’s Phone No.               37.  Physician’s Signature                                                                                                                                             

ASSESSMENT TEAM USE ONLY

43.   Nursing Facility Level of Care             Yes     No                                                                                                    44.  L.O.S.                                                           Certified Through Date            

45.  Signed by person certifying LOC:                                                                                                                 Title                                                                       Date Signe

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