
___________________________ _________________________________________________________________________________________________________ DOH-4397 Part B (03/08) Rev. 09/12 Page 1 of 6 ASSISTED LIVING RESIDENCE RESIDENT EVALUATION New York State Department of Health Division of Assisted Living Resident’s Name: _________________________________________________________________________________ Facility Name: ________________________________________ Date of Evaluation: __________________________.
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How to fill out the DOH-4397 online
The DOH-4397, also known as the resident evaluation form for assisted living residences, is essential for ensuring the proper assessment of individual needs. This guide provides a clear and supportive walkthrough to help users effectively complete the form online.
Follow the steps to successfully complete the DOH-4397 form.
- Click ‘Get Form’ button to access the document and open it in the online editor.
- Begin by filling in the resident's name, facility name, and the date of the evaluation in the designated fields at the top of the form. Ensure accuracy, as this information is crucial for identification and records.
- Proceed to Section 1, which focuses on communication, dental, vision, and hearing capabilities. Answer the questions by selecting the appropriate checkboxes. If any responses indicate language barriers, be sure to note the dominant language as specified.
- In Section 2, describe the resident's customary routine including sleeping, napping, and bathing preferences. Provide detailed comments regarding daily events, such as how often they engage with others or participate in activities.
- Section 3 requires you to evaluate continence status. Answer whether the resident is continent for urinary and bowel functions, and if not, fill in the subsequent fields detailing the frequency and management techniques.
- Move to Section 4 to assess physical function. Fill out the tasks listed, indicating the level of assistance the resident requires for activities such as eating, bathing, dressing, and toileting. Use the comments section to provide additional context.
- In Section 5, evaluate cognitive functioning and check the appropriate responses regarding alertness and orientation while noting any behaviors of concern.
- Finally, complete Section 6, which involves the admission decision. Select the appropriate category and ensure all signatures, including those of staff and the resident, are obtained.
- Once you have filled out all sections, review the document for completeness. Make any necessary edits, and then save your changes. You can also download, print, or share the completed form as needed.
Start filling out the DOH-4397 online today to ensure a thorough resident evaluation.
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