HTML Preview Personal Physician Care Plan page number 1.
DMA-3050-R
ADULT CARE HOME
PERSONAL CARE PHYSICIAN AUTHORIZATION AND CARE PLAN
RESIDENT INFORMATION
(Please Print or Type)
RESIDENT _________________________________________ SEX (M/F) ____ DOB ____/____/____ MEDICAID ID NO. __________________________
FACILITY ____________________________________________________________________________________________________________________________
ADDRESS ___________________________________________________________________________________________________________________________
___________________________________________________________________PHONE ___________________ PROVIDER NUMBER __________________
DATE OF MOST RECENT EXAMINATION BY RESIDENT’S PRIMARY CARE PHYSICIAN ______/______/______
ASSESSMENT
1. MEDICATIONS – Identify and report all medications, including non-prescription meds, that will continue upon admission:
Name
Dose Frequency Route
(
) If Self-Administered
2. MENTAL HEALTH AND SOCIAL HISTORY: (If checked, explain in “Social/Mental Health History” section)
Wandering
Verbally Abusive
Physically Abusive
Resists care
Suicidal
Homicidal
Disruptive Behavior/
Socially Inappropriate
Injurious to:
Self Others Property
Is the resident currently receiving
medication(s) for mental illness/behavior?
YES NO
Is there a history of:
Substance Abuse
Developmental Disabilities (DD)
Mental Illness
Is the resident currently receiving Mental Health, DD, or
Substance Abuse Services (SAS)?
YES NO
Has a referral been made?
YES NO
If YES:
Date of Referral _________________
Name of Contact Person _____________________________
Agency ______________________________________________
Social/Mental Health History: ________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Assessment Date ___/___/___
Reassessment Date ___/___/___
Significant Change___/___/___