Get Dms 1

NEW YORK STATE HEALTH DEPARTMENT NUMERICAL STANDARDS MASTER SHEET NUMERICAL STANDARDS FOR APPLICATION FOR THE LONG TERM CARE PLACEMENT FORM MEDICAL ASSESSMENT ABSTRACT DMS-1 3. a* Nursing Care and Therapy Specify details in 3d 3e or attachment Frequency Self Care None Day Shift Night/Eve. Shift Parenteral Meds Inhalation Treatment Oxygen Suctioning Aseptic Dressing Lesion Irrigation Cath/Tube Irrigation Ostomy Care Parenteral Fluids Tube Feedings Bowel/Bladder Rehab. Bedsore Treatment Other Describe Yes Can Be Trained No b. Incontinent Urine Stool Often 20 Seldom 10 c* Does patient need a special diet No Never 0 Foley 15 If yes describe Function Status Walks with or w/o aids Transferring Wheeling Eating/Feeding Tolieting Bathing Dressing Some Help Total Help Cannot Mental Status Alert Impaired Judgement Agitated nightime Hallucinates Severe Depression Assaultive Abusive Restraint Order Regressive Behavior Wanders Other Specify Sometimes Always Partial Total Impairments Sight Hearing Speech Communications Other Contractures etc* Short Term Rehab. Therapy Plan To be completed by Therapist a* Describe Condition not Dx Needing Intervention Short Term Plan of Treatment Eval* and Progress in last 2 weeks Achievement Date Circle Minimum number of days/week of skilled therapy from each of the following REQUIRES 01234567 RECEIVES PT OT SPEECH 37 for skilled rehab/therapy received required both 0. a* Nursing Care and Therapy Specify details in 3d 3e or attachment Frequency Self Care None Day Shift Night/Eve. Shift Parenteral Meds Inhalation Treatment Oxygen Suctioning Aseptic Dressing Lesion Irrigation Cath/Tube Irrigation Ostomy Care Parenteral Fluids Tube Feedings Bowel/Bladder Rehab. Shift Parenteral Meds Inhalation Treatment Oxygen Suctioning Aseptic Dressing Lesion Irrigation Cath/Tube Irrigation Ostomy Care Parenteral Fluids Tube Feedings Bowel/Bladder Rehab. Bedsore Treatment Other Describe Yes Can Be Trained No b. Incontinent Urine Stool Often 20 Seldom 10 c* Does patient need a special diet No Never 0 Foley 15 If yes describe Function Status Walks with or w/o aids Transferring Wheeling Eating/Feeding Tolieting Bathing Dressing Some Help Total Help Cannot Mental Status Alert Impaired Judgement Agitated nightime Hallucinates Severe Depression Assaultive Abusive Restraint Order Regressive Behavior Wanders Other Specify Sometimes Always Partial Total Impairments Sight Hearing Speech Communications Other Contractures etc* Short Term Rehab. Bedsore Treatment Other Describe Yes Can Be Trained No b. Incontinent Urine Stool Often 20 Seldom 10 c* Does patient need a special diet No Never 0 Foley 15 If yes describe Function Status Walks with or w/o aids Transferring Wheeling Eating/Feeding Tolieting Bathing Dressing Some Help Total Help Cannot Mental Status Alert Impaired Judgement Agitated nightime Hallucinates Severe Depression Assaultive Abusive Restraint Order Regressive Behavior Wanders Other Specify Sometimes Always Partial Total Impairments Sight Hearing Speech Communications Other Contractures etc* Short Term Rehab. Therapy Plan To be completed by Therapist a* Describe Condition not Dx Needing Intervention Short Term Plan of Treatment Eval* and Progress in last 2 weeks Achievement Date Circle Minimum number of days/week of skilled therapy from each of the following REQUIRES 01234567 RECEIVES PT OT SPEECH 37 for skilled rehab/therapy received required both 0.