Transcription of INSTRUCTIONS TO LICENSED HEALTH CARE …
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1 AHCA Recommended Form 1823 9/2013 RESIDENT HEALTH assessment for ASSISTED LIVING FACILITIES This form must be completed annually for residents receiving assistive care services in order to comply with Medicaid TO BE COMPLETED BY FACILITY: Resident s Name DOB: INSTRUCTIONS TO LICENSED HEALTH CARE PROVIDERS: AFTER COMPLETION OF ALL ITEMS IN SECTIONS 1 AND 2 OF THIS FORM (pages 1 through 4), PLEASE RETURN TO: FACILITY NAME: FACILITY ADDRESS: TELEPHONE NUMBER: CONTACT PERSON: SECTION 1: HEALTH assessment (MUST BE COMPLETED BY A LICENSED HEALTH CARE PROVIDER BY MEANS OF A FACE-TO-FACE EXAMINATION WITH THE RESIDENT.) Known Allergies: Height: Weight: Medical history and diagnoses: Physical or sensory limitations: Cognitive or behavioral status: Nursing/treatment/therapy service requirements: Special precautions: Elopement Risk: Yes No AHCA Recommended Form 1823 2 TO BE COMPLETED BY FACILITY: Resident s Name DOB: SECTION 1: HEALTH assessment (MUST BE COMPLETED BY A LICENSED HEALTH CARE PROVIDER BY MEAN)
4 ahca recommended form 1823 to be completed by facility: resident’s name dob: section 2-b: self-care and general oversight assessment—medications (must be
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ASSISTANCE WITH SELF-ADMINISTRATION OF, Assistance with self-administration of medications, Self-Administration Assessment, Assessment, Home Health Care, Self Assessment, Use of dose administration aids by nurses, Self, Assessment of Sedation During Opioid, Assessment of Sedation During Opioid Administration, Board Approved Medications for Credentialed EMS Personnel, Medications, Computerized Neuropsychological Assessment, Long Term Care, PHYSICIAN ORDER FOR SKILLED