Get Ny Doh-3122 2012-2026

Filling out the NY DOH-3122, the Assisted Living Residence Medical Evaluation form, is a crucial step in ensuring proper care for individuals in assisted living facilities. This guide provides clear, step-by-step instructions to help you navigate the online completion of this important document.

Follow the steps to successfully complete the NY DOH-3122 form.

1. Press the ‘Get Form’ button to access the NY DOH-3122 form and open it in the editor.
2. Begin by filling in the resident's name at the top of the form. Ensure that all spaces are completed accurately.
3. Select the reason for evaluation by checking the appropriate box: Pre-Admission, 12 month, Acute change in condition, or Other. If you select 'Other', specify the reason in the provided space.
4. Input the vital signs, including blood pressure, pulse, respiration rate, temperature, height, and weight. Then, list the primary and secondary diagnosis(es) as necessary.
5. Note any known allergies by checking the 'None' box or providing a list of known allergies if applicable. Indicate the dietary requirements by selecting options based on the resident's needs.
6. Fill out the immunization history, including the dates of vaccinations for influenza and pneumococcal vaccine if applicable. Complete the TB screening section based on the resident's recent medical history.
7. Complete the continence section by indicating the status of bladder and bowel control and whether any management is needed.
8. Proceed to the activities of daily living (ADL’s) section. Document any activity restrictions and the level of assistance required for ambulation, transfer, feeding, and managing medical equipment.
9. In the additional services section, indicate any pertinent medical or mental findings and specify any recommended therapies or home care needs.
10. Complete the cognitive impairment and mental health assessment sections. Indicate if the resident shows signs of dementia or mental health issues, and provide recommendations if necessary.
11. Detail the medications section by listing all prescription, over-the-counter medications, supplements, and vitamins as required. Ensure to attach any additional documentation if necessary.
12. Finally, complete the physician certification section. The certifying physician must sign and date the form, ensuring all information is accurate.
13. Once all sections are filled, save changes, and choose between options to download, print, or share the completed form as needed.

Start your document submission process by completing the NY DOH-3122 online today.