MATRIX HOME CARE MEDICAL SOCIAL WORK …

1 Name of Responsible Person: Relationship: Phone: PT/CL Name: Date: Address: Person to Contact in Emergency: Relationship: Phone: City, State, Zip: Phone: Sex M F Prior MEDICAL SOCIAL work Service Referral Source/Date Frequency/Duration of Visit Rehabilitation Potential Physician Phone Diagnosis Date of Onset AGENCY/SNF: Dates of Stay: Primary Secondary AGENCY/SNF: Dates of Stay: SPECIFIC INFORMATION DESIRED_____ I. PERSONAL, PSYCHOSOCIAL AND FAMILY FUNCTIONING AND FINANCIAL INFORMATION: A. HOUSEHOLD MEMBERS SIGNIFICANT OTHERS COMMENTS (names and relationships) (names and relationships)_____ B.

2 BEHAVIOR INDICATORS/PSYCHOSOCIAL FUNCTIONING. Key PT = Patient PCP = Primary care Person GOOD FAIR POOR COMMENTS PT PCP PT PCP PT PCPF unctional AbilityMemoryComprehensionJudgement/Deci sion MakingCommunciation AbilityKnowledge of Health ProblemsMotivation to Resolve NeedsCompliance with TreatmentAbility to Accept Help C. Significant psycho/ SOCIAL /emotional factors/needs for counseling:_____ Refer to Case Manager: _____ Psych Nurse: _____ MHMR:_____ Other:_____Client/Designee: I certify that the MATRIX home Cae Employee listed on this time slip worked the times indicated and the owrk was performed in a satisfavory manner.

3 I agree to the times regarding this time Signature: _____Patient/Client Signature: _____PT/CL NAME: _____ADDRESS: _____CITY, STATE, ZIP: _____VISITDATE: _____TIME IN:_____TIME OUT: _____10/09/12 MEDICAL SOCIAL work assessment Page 1 of 2 MATRIX home care MEDICAL SOCIAL work ASSESSMENTMATRIX home care MEDICAL SOCIAL work ASSESSMENTP atient/Client Name: _____Date: _____II. ASSESMENT SUMMARY:III. LONG-TERM care PLANNING: _____ Access community resourse utiliztion on ongoing basis _____ Provide information, referral consultation & collateral contacts as needed _____ Counsel/teach re: appropriate community resourse utilization _____ Instruct pt/family to call care Team if assistance needed after Areas/Reasons: Indentify factors which are impeding patients ability to achieve maximal health potential/compliance with treatment : Adequate YES NODue to: Crowing Santitation Structural deficiency Neighborhood Dysfunctional utilities Other.

4 _____ EQUIPMENT/SUPPLIES/INFORMATION: Adequate YES NO Due to: Knowledge deficit Income deficit Other: _____INCOME: Adequate YES NODue to: No income resource Disproportionate living or MEDICAL expenses Poor financial planning/ decision making Other: _____SAFETY: Adequate YES NODue to: Lack of supervision Abuse/neglect Poor judgement Environment Alcohol/substance abuse Prome to falls or MEDICAL emergencies Other: _____TRANSPORATION: Adequate YES NODue to: Unable to drive Unable to ride in car Driver no available Can t afford Inaccessibility Other: _____PERSONAL care /HOUSEKEEPING: Adequate YES NODue to: Lives alone Elderly/ill PCP Extreme dependency of pt.

5 Employed PCP Refuses to accept help Cannot afford to hire Other: _____FOOD MEALS: Adequate YES NODue to: Pt/PCP unable to prepare meals Inadequate income Inability to shop for groceries Other: _____OTHER: _____Comments: _____Signature: _____ Date: _____10/09/12 MEDICAL SOCIAL work assessment Page 2 of 2