MOVE-IN ORDERS ASSISTED LIVING
RESIDENT NAME
DATE OF BIRTH
/
Month
/
Day
Year
Date
DATE OF PHYSICAL MOVE IN
/
Month
/
Day
Year
Date
APARTMENT #
ALLERGIES
DIAGNOSIS
CPR Status
Do Not Resuscitate
FULL CODE
Tuberculosis
TB SCREENING UPON ADMISSION AND ANNUALLY
2 STEP TB TEST UPON ADMISSION AND 1 STEP ANNUALLY
CXR REQUIRED
Free of pulmonary TB symptoms?
Yes
No
DATE OF LAST TB TEST OR LAST CHEST X RAY
/
Month
/
Day
Year
Date
RESIDENT IS FREE OF COMMUNICABLE DISEASES AND HAS A CHRONIC AND STABLE CONDITION
Yes
No
INFLUENZA/PNEUMONIA: RESIDENT MAY HAVE ANNUAL FLU VACCINE PER MANUFACTURER’S GUIDELINES AND CDC GUIDELINES
Yes
No
RESIDENT HAS DOCUMENTED PNEUMONIA VACCINE ON FILE.
Yes
No, please administer with resident consent
Unknown, ok to administer with consent
DIET: (PLEASE SELECT ALL THAT APPLY)
RESIDENT MAY SELF-DIRECT
REGULAR/GENERAL DIET
NO CONCENTRATED SWEETS /ADDED SUGAR
NO ADDED SALT
NO DAIRY
NO SHELLFISH
TEXTURE CONSISTENCY
REGULAR
THIN/REGULAR
MECHANICAL SOFT
NECTAR THICK
CHOPPED
HONEY THICK
PUREED
PUDDING THICK
HEALTH CARE PROVIDER NAME
NPI #
TELEPHONE NUMBER
FAX NUMBER
SIGNATURE (MD or NP ) - Skip if you're not
DATE
/
Month
/
Day
Year
Date
RESIDENT NAME
DATE OF BIRTH
/
Month
/
Day
Year
Date
DATE OF PHYSICAL MOVE IN
/
Month
/
Day
Year
Date
APARTMENT #
OK TO TREAT
SKIN TEARS
REDDENED AREA
SCRAPES AND ABRASTIONS
RASHES AND BLISTERS
IMMODUIM 2 MG TABS FOR DIARRHEA
MILK OF MAGNESIA FOR CONSTIPATION
MYLANTA FOR UPSET STOMACH OR HEARTBURN
ACETAMINOPHEN 325 MG FOR PAIN OR FEVER
MEDICATION MANAGEMENT (Check as indicated)
PRN MEDICATIONS WHICH HAVE NOT BEEN USED FOR 60 DAYS OR MORE DAYS MAY BE DISCONTINUED AT LICENSED NURSES’ DISCRETION.
COMMUNITY MAY INITIATE INCREASED CALORIC INTAKE INCLUDING: MILKSHAKES/HEALTH SHAKES OR EQUIVALENT FOR NUTRITIONAL SUPPLEMENTS AND/OR WEIGHT LOSS.
BEGIN ALL NEW ORDERS WHEN MEDICATION IS AVAILABLE FROM PHARMACY
ALL NEW ORDERS FILLED FOR 31 DAY SUPPLY AND CONTINUE FOR 180 DAYS UNLESS OTHERWISE INDICATED IN ORDER
MAY UTILIZE GENERIC EQUIVALENTS UNLESS SPECIFIED IN ORDER
RESIDENTS WITH DIAGNOSIS OF DIABETES MAY HAVE CBG CHECKED PRN AS DIRECTED BY NURSE, PER RESIDENT REQUEST OR BASED ON SYMPTOMS OF HIGH OR LOW BLOOD SUGAR.
RESIDENT MAY TAKE MEDICATIONS OUT ON PASS PER COMMUNITY POLICY
RESIDENT MAY SELF-ADMINISTER MEDICATIONS IF SELF-MEDICATION EVALUATION INDICATES THAT RESIDENT IS ABLE ADMINISTER AND STORE MEDICATIONS SAFELY.
NOTIFY THE MEDICAL PROVIDER OF THE FOLLOWING:
OTC
PRESCRIBED
WHEN RESIDENT MISSES DOSES OF SCHEDULED MEDICATIONS/TREATMENTS
OTC
PRESCRIBED
HEALTH CARE PROVIDER NAME
NPI #
TELEPHONE NUMBER
Format: (000) 000-0000.
FAX NUMBER
SIGNATURE
DATE
/
Month
/
Day
Year
Date
MOVE-IN ORDERS ASSISTED LIVING
RESIDENT NAME
DATE OF BIRTH
/
Month
/
Day
Year
Date
DATE OF PHYSICAL MOVE IN
/
Month
/
Day
Year
Date
APARTMENT #
HEALTH CARE PROVIDER NAME
NPI #
TELEPHONE NUMBER
Format: (000) 000-0000.
FAX NUMBER
SIGNATURE
DATE
/
Month
/
Day
Year
Date
RESIDENT NAME
DATE OF BIRTH
/
Month
/
Day
Year
Date
DATE OF PHYSICAL MOVE IN
/
Month
/
Day
Year
Date
APARTMENT #
HEALTH CARE PROVIDER NAME
NPI #
TELEPHONE NUMBER
Format: (000) 000-0000.
FAX NUMBER
SIGNATURE
DATE
/
Month
/
Day
Year
Date
Frontier Management, LLC
Updated December 2021
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