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Appendix
 Schematic – Conceptual Representation of Clinical Conditions
 Underlying Alterations/Clinical Syndrome of Frailty/Adverse Outcomes of
Frailty
 Mini Nutritional Assessment (MNA®)
 BMI Score
 Weight Loss Score
 Estimating Height From Ulna Length
 Estimating BMI Category From Mld Upper Arm Circumference (MUAC)
 Mini-Mental State Examination
 Evaluation of the Older Adult Who is Failing in the Community
 Anthropometric Measurements
 Failure to Thrive in Elderly Patients
 Documentation Tips
 Workshop Question Form
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Schematic – Conceptual Representation of Clinical Conditions
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Mini-Mental State Examination
( ) 1. What is the year ______, season ______, date ______, day ______, month ______.
( ) 2. What are we: state ______, county ______, town ______, hospital ______, floor ______.
( ) 3. Name 3 objects: orange ______, airplane ______, tobacco ______. (trails ______).
( ) 4. Serial 7's: ______ ______ ______ ______ ______
(93)
(86) (79)
(72) (65)
or spell "world" backwards ____ ____ ____ ____ ____
(d) (l) (r) (o) (w)
( ) 5. Recall 3 objects: orange ______, airplane ______, tobacco ______.
( ) 6. Name a pencil ______, and watch ______.
( ) 7. Read and obey ______ CLOSE YOUR EYES
( ) 8. Copy design ______ (below)
( ) 9. Write a sentence ______ (below).
( ) 10. Repeat the following "no ifs, ands, or buts" ______.
( ) 11. Follow a 3-stage command: a: take a paper in your right hand ______
b. fold it in half ______
c. put it on the floor ______
Level of consciousness ______________________________________ (check)
alert
drowsy
stupor
coma
Total (One point for each blank, maximum = 30)
signature _______________________ Date Physician _________________
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Evaluation of the older adult who is failing in the community
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Anthropometric Measurements
Values showing
malnutrition
Test
Gender
Normal values
Triceps skinfold (TSF)
Male
11–12.5 mm
7.5–11 mm
Female
15–16.5 mm
10–15 mm
Male
26–29 cm
20–26 cm
Female
26–28.5 cm
20–26 cm
Male
23–25 cm
16–23 cm
Female
20–23 cm
14–20 cm
Mid upper arm
circumference (MUAC
Arm muscle circumference
(AMC)
AMC = MUAC – 0.314 = TSF
Jonas: Mosby's Dictionary of Complementary and Alternative Medicine. (c) 2005, Elsevier
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Documentation Tips
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Question Contact Form
Workshop Location and Date:_____________________________________________
Name: _______________________________________________________________
Position or Title: _______________________________________________________
Agency Name: _________________________________________________________
Provider #: ____________________________________________________________
Phone #: _____________________________________________________________
Fax #: _______________________________________________________________
Email: _______________________________________________________________
Question(s):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Disclaimer: This form is for use in conveying general questions only and may not contain information that is privileged and
confidential, specifically Protected Health Information (PHI). If you have a question about a specific claim, please request
a call for follow up. Thank you.
Revision #1
Revision date 08-02-2006 MR-QSF-7.5.1 LPET – Question Contact Form
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