Today’s date:
Rehabilitation
Assessment
Form
Complete this form and fax it to:
1-844-869-4073
Include hospital admission H&P and any PM&R consultation
notes. For HMO and PPO members in a SNF, fax signed /
dated NOMNC form prior to discharge.
ASSESSMENT TYPE / COVERAGE
Assessment type: q Initial assessment q Reassessment Plan: q Medi-Pak® Advantage HMO q Medi-Pak® Advantage PPO
MEMBER / FACILITY INFORMATION
Member name:
Age:
Authorization number:
Contract number:
Facility reviewer for updates:
Admitting facility:
Phone:
Fax:
Admission type: q SNF
q IP rehab
Team conference day:
ADMISSION INFORMATION
CLINICAL INFORMATION / BASICS
(Complete this section for the initial assessment only.)
Vital signs: T
P
R
BP
Admission date (facility):
Cognition / A&O: q x1 q x2 q x3
Facility doctor first / last name:
Bowel: q Continent q Incontinent q Ostomy
Bladder: q Continent q Incontinent q Cath / Type:
DX:
Diet: q NPO or q Type:
PMH:
Tube feeding: Formula / Rate:
PSH:
O2 delivery: Type:
Sats:
Height:
Weight:
Respiratory tx: q Yes q No
Prior level of function (home):
Trach: Type:
Size:
Home configuration:
Suction frequency/24H:
No. of steps at entry:
Pain location / mgt:
Location of: Bed:
Bath:
MOBILITY CURRENT FUNCTIONING (Use key below.*)
CLINICAL INFORMATION / MEDICATIONS
Bed mobility:
IV medications, with ending dates:
Transfers:
Vascular access:
Gait / Distance:
Assist level:
Significant medications that affect functioning:
Assistive device: q None or q Type:
Stairs / Ascending, descending: q Not applicable or
No. of stairs:
WC mobility:
Distance:
Handrails:
Assist needed:
Assist needed:
SELF-CARE CURRENT FUNCTIONING (Use key below.*)
Feeding:
Grooming:
Bathing / UE:
LE:
Dressing / UE:
LE:
Toileting / Hygiene Mgt:
ADL transfers:
Comments:
CLINICAL INFORMATION / SKIN STATUS
Skin status: q Intact or...
If not intact, complete fields below and add pages as needed.
Wound or incision / Location 1 -- Stage:
Size: L x W x D (cm):
Treatment:
Wound or incision / Location 2 -- Stage:
Size: L x W x D (cm):
Treatment:
DISCHARGE (DC) PLANS
DC date (tentative):
DC with: q HHC provider:
SPEECH THERAPY CURRENT STATUS
q OP provider:
q None or q Dysphagia Eval. / Modified Barium
DC
equipment
(prior auth required**):
Swallow Results / Aspiration Risk / Recommendations:
DC destination:
Member to live with:
Supervision needs:
*Key for mobility and self-care functioning:
I = independent / MI = modified independent / Sup = supervision
SBA = standby assist / CGA = contact guard assist / Min = minimal
Mod = moderate / Max = maximum / Total = total assist
DC goals:
page 1
Revised August 2015
Rehabilitation
Assessment
Form
Member name:
Contract number:
Complete this form and fax it to:
1-844-869-4073
Include hospital admission H&P and any PM&R
consultation notes. For HMO and PPO members in a
SNF, fax signed / dated NOMNC form prior to discharge.
Admitting facility:
Today’s date:
ADDITIONAL NOTES
page 2
Revised August 2015