Transcription
PASRRResident Review/ID or DUSection I: IdentificationPAS/ID/IDDGender MaleName (Last, First, MI)Date of BirthPAS/DUAL (IMI and ID/IDD)FemaleSS# (last 4 digits)AgeEvaluation DateAdmit DateFacility Name:AddressCityState ARZip CodeContact personPhoneDoes the individual have a LEGAL GUARDIAN?FaxNoIf Yes, complete the following:NamePhoneAddressCityState ARZip CodeRelationship: [Select or type response]Section II: Psychological Assessment1. Please list all documented historical and current psychiatric diagnoses.2. Describe historical symptoms or behaviors indicating a psychiatric disorder and time of onset.Arkansas Resident Review ID or DU (April 2022)1Bock Associates
Section II: Psychological Assessment (continued)3. Describe any previous psychiatric treatment including hospitalizations, outpatient treatment, etc.4. Describe current symptoms or behaviors indicating a psychiatric disorder.5. Current psychiatric treatment (check all that apply)Medication therapy, administration, monitoringIndividual therapy/counselingOutpatient psychiatric follow-upDay program/partial hospital programInpatient psychiatric treatmentSheltered workshopGroup therapy/counselingECTOther (specify):Precautions (specify):6. Does the client have a history of alcohol/drug abuse and/or treatment?NoIf yes, describe:Last known use:Arkansas Resident Review ID or DU (April 2022)2Bock Associates
Section III: Behavioral AssessmentA. Problematic Behaviors:NoneIf yes, please indicate which of the following behaviors are problematic for the individual within the last 30 days based on theindividual's medical record or staff comments.Dangerous smoking behaviorRefuses medicationsRefuses activitiesRefuses to eatUncooperative with dietUncooperative with hygieneSelf induced vomitingImpatient/demandingFrequent/continuous yellingFrequent/continuous whiningWanderingOther (specify):Alcohol/drug useDestroys propertyExposes selfSexually aggressiveVerbally abusiveVerbally threateningCursing/swearingDisturbs other residentsPhysically threateningStrikes others provokedStrikes others unprovokedPacingTries to escapeSeclusivenessSuspicious of othersLies purposefullySteals deliberatelyTalks of suicide/ideationPassive death wishSuicide threatsSuicide attemptsInjures selfB. Placement in Seclusion/RestraintsIn the last 30 days has the individual been placed in seclusion or restraints to control dangerous behavior?NoIf Yes, complete the following:Type of RestraintDateDurationBehavior/precipitating eventC. Typical Daily ActivitiesPer client and/or staff report, describe how the individual spends most of her/his time:Arkansas Resident Review ID or DU (April 2022)3Bock Associates
Section IV: Medical History/TreatmentA. Medical Diagnoses. List all medical diagnosis as documented in the client's record.B. Current Medications. Record medications, excluding convenience medications)Drug NameDosageFrequencyCurrent MAR is attachedStart DateC. STAT/PRN Medications.In the last 30 days, has the individual received an emergency (STAT) or PRN administration of medications to control her/hisNoIf Yes, complete the following:behavior?Drug NameArkansas Resident Review ID or DU (April 2022)DosageDate Given4Precipitating Event/BehaviorBock Associates
Section IV: Medical History/Treatment (continued)D. Special Medical Treatments. Does the individual currently receive any special medical treatments?NoIf yes, please indicate which of the following treatments the individual receives (check all that apply).Bowel and bladderTracheostomy careMedication monitoringSterile dressingCatheterization carePosey/soft restraintsOral suctionWound/incision careColostomy/illeostomySeizure precautionsTube feedings/TPNDecubitus careFormal behavior modificationGeri chairSymptom control (terminalillness)Diabetic monitoringIV meds/antibioticsOxygenTPR/BPFracture careInhalation therapyProsthesis careDietary supplementsGastrostomyIntake and outputRestraintsWeight monitoringBlood transfusionsIV fluidsSpecial skin careTherapeutic diet (specify):Ordered labs (specify):Other (specify):E. Rehabilitative Services. Does the client receive any type of rehabilitative services?NoIf yes, please indicate services received:Physical therapySpeech therapyOccupational therapyRestorative nursingCOMMENTSArkansas Resident Review ID or DU (April 2022)5Bock Associates
Service RecommendationsSpecialized Services: Defined as the implementation of an individualized program plan developed by an IDT & provided by a QDDP that represents areas that are relevant toidentifying the individual's needs, directing them toward the acquisition of behaviors necessary to function with as much self-determination and independence as possibleBased on the individual's physical and mental condition and the above definition:YesNo1. This person requires the level of care provided in a nursing facilityYesNo2. Specialized services recommendedThese are services provided outside the NF setting - 6 hrs/day, 5 days/week REGARDLESS of physical limitations.* Sheltered Workshop: Skill preparation for vocational opportunities* Adult Education: Provide access to community by developing living skillsYesNo3. Health rehabilitative services recommended (In order to check Yes, you MUST recommend NF placement)Structured environmentFormal behavior modificationIndividual psychotherapyDaily living skills trainingCommunity supportCrisis interventionDevelop support networksPharmacologic management by PhysicianOther:YesNo4. Other services are recommended for this person (specify):YesNo5. This person would not benefit from specialized services due to advanced ageYesNo6. This person would not benefit from specialized services due to severe illnessDevelopment and Placement RecommendationsRecommendations are provided to assist the IDT in developing and individualized care plan1. Adult Development1. Personal Hygiene5. Eating9. Bed Mobility13. Leisure2. Toileting6. Rehabilitative Therapy10. Locomotion14. Socialization3. Bathing7. Speech Therapy11. Behavior Management4. Dressing8. Transferring12. Pre-Vocational Training15. Other:2. Work Activity1. Supported Employment2. Competitive Employment3. Community-Based Habilitative Training1. Food preparation4. Laundry7. Medication administration2. Household safety5. Community integration8. Money management3. Sexuality6. Transportation9. Other:4. Alternative Placement OptionsResidential Care FacilityGroup HomeICF/IDSupervised apartmentAssisted Living FacilityOwn home or other residencePost Acute Head Injury FacilityResidential Treatment FacilityDementia/Alzheimer's Unit (specify):DDS Group HomeMedicaid Waiver ServicesHuman Development CenterOther:Assisted Living FacilityAssessor Signature:Arkansas Resident Review ID or DU (April 2022)Date:6Bock Associates
Specialized Services: Defined as the implementation of an individualized program plan developed by an IDT & provided by a QDDP that represents areas that are relevant to identifying the individual's needs, directing them toward the acquisition of behaviors necessary to function with as much self-determination and independence as possible
