FRONTIER MEMORY CARE MOVE-IN ORDERS

1
RESIDENT NAME
2
DATE OF BIRTH
Date
Month
Day
Year
3
DATE OF PHYSICAL MOVE IN
Date
Month
Day
Year
4
APARTMENT #
5
ALLERGIES
6
DIAGNOSIS
7
This Resident has a diagnosis of one of the following:
Dementia
Alzheimer's
Cognitive Impairment requiring a secure memory care community
8
CPR Status
Do Not Resuscitate
Full Code
9
Tuberculosis
TB SCREENING UPON ADMISSION AND ANNUALLY
2 STEP TB TEST UPON ADMISSION AND 1 STEP ANNUALLY
CXR REQUIRED
10
IS YOUR PATIENT FREE OF SIGNS/SYMPTOMS OFPULMONARY TB?
Yes
No
11
DATE OF LAST TB TEST OR LAST CHEST X RAY
Date
Month
Day
Year
12
RESIDENT IS FREE OF COMMUNICABLE DISEASES AND HAS A CHRONIC AND STABLE CONDITION
Yes
No
13
RESIDENT MAY HAVE ANNUAL FLU VACCINE PER MANUFACTURER'S GUIDELINES AND CDC GUIDELINES
Yes
No
14
RESIDENT HAS DOCUMENTED PNEUMONIA VACCINE ON FILE.
YES, ATTACHED IN RECORD
NO, PLEASE ADMINISTER WITH RESIDENT CONSENT
Unknown, PLEASE ADMINISTER WITH CONSENT
15
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
16
HEALTH CARE PROVIDER NAME
17
NPI #
18
Telephone Number
19
DATE
Date
Month
Day
Year
20
FOOD TEXTURE
REGULAR
MECHANICAL SOFT
CHOPPED
PUREED
21
LIQUID CONSISTENCY
THIN/REGULAR
NECTAR THICK
HONEY THICK
PUDDING THICK
22
STANDING ORDERS
SKIN TEARS
REDDENED AREA
OPEN AREA
SCRAPES
23
Standing Orders
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.
24
NOTIFICATION OF MISSED MEDICATIONS
WHEN RESIDENT MISSES ANY SCHEDULED MEDICATION/TREATMENT OTC
WHEN RESIDENT MISSES ANY SCHEDULED MEDICATION/TREATMENT PRESCRIBED
25
PROVIDER SIGNATURE (SKIP AND SUBMIT IF NOT PROVIDER)
Clear
Should be Empty: