BROOKDALE Physician Plan Of Care

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Plan of Care Quick Form: Brookdale

Plan of Care Quick Form: Brookdale

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59Questions

HIPAA

Compliance

1
Person filling this form
2
Email or fax to send completed form
3
Resident Name
4
Date of Provider Visit
Date
Month
Day
Year
5
Resident's Date of Birth
6
Physician Name
7
Physician/HCP Address
8
Physician Phone
9
Fax Number
10
Primary Medical Diagnosis
11
Secondary Diagonses (list all)
12
Allergies (medication, environment, food)
13
Does the resident have a Molst/Polst/DNR?
Yes
No
14
Current Treatments
15
Can they self administer medications without staff supervision?
Yes
No
16
Resident's Name
17
Date of Physician/HCP Visit
Date
Month
Day
Year
18
Medications: List Name, Route, Dose, Frequency, Indication (up to 10)
19
Type a question
Ok to fill 30 day supply with 12 refills
May crush medication
20
Date of last TB skin or lab test
21
Result
22
Date of last Chest x-ray
23
Result
24
If done, approximate pneumonia vaccine date:
25
If done, approximate Tetanus-Diphtheria vaccine date:
26
Ok to administer flu vaccine annually?
Yes
No
27
Ok to drink alcohol?
Yes
No
28
Ok to exercise as tolerated?
Yes
No
29
Resident's Name
30
Date of Physician/HCP Visit
Date
Month
Day
Year
31
Has the resident received COVID vaccine?
Yes
No
32
Type (i.e., Pfizer, Moderna, Johnson & Johnson etc.)
33
If yes, date of 1st dose
Date
Month
Day
Year
34
If yes, date of 2nd dose
Date
Month
Day
Year
35
If yes, date of 3rd dose
Date
Month
Day
Year
36
Did the resident refuse the vaccine?
Yes
No
37
if yes reason why
38
Ok to administer COVID vaccine as recommended by CDC?
Yes
No
39
If no, why
40
OK to test for COVID?
Yes
No
41
Has resident ever been tested for COVID?
Yes
No
42
Test result positive or negative?
Positive
Negative
43
Date of result
Date
Month
Day
Year
44
If recently positive and moderate illness, at least 10 days passed since first symptoms?
Yes
No
N/A
45
If recently positive and severe illness, >24 hours since last fever, other symptoms improved, and at least 10 days passed since first symptoms?
Yes
No
N/A
46
Resident's Name
47
Date of Physician/HCP Visit
Date
Month
Day
Year
48
Available Diets
Regular
Texture Modified
Puree
No Salt Added
2 gm Sodiuim
Carbohydrate Controlled (diabetic)
Low Fat / Low Cholesterol
Renal / Kidney Diet
Finger Food
49
Liquid Thickeners
Nectar
Honey
50
Supplements
51
Resident's Name
52
Date of Physician/HCP Visit
Date
Month
Day
Year
53
Skilled Services requested
Skilled Nursing
Speech Therapy
Physical Therapy
Occupational Therapy
54
If Skilled services needed, Face to Face Encounter Date
55
Assistive Devices
56
Other Instructions
57
Provider signature (click Next if not the provider)
Clear
58
NPI
59
Date
Date
Month
Day
Year
Should be Empty:

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