MOVE-IN ORDERS ASSISTED LIVING
Please confirm all relevant information, without signing, click Submit, then Provider will review and sign, and email back to you. Please encourage family to email any available medical records to our HIPAA secure email admin@fhpgeriatrics.com. We are available for telemedicine exam prior to move in, in order to complete assessment and have prescriptions, home health orders, therapy orders, labs orders, and fresh look at their treatment plan, prior to moving in. They may also request our Patient Portal to send us secure messages, confirm medications, and review lab results we order.
FHP Geriatrics, Dr.George Valdez, MD, MBA
Phone 832-599-8336 Fax 888-840-6973
RESIDENT NAME
FACILITY NAME
ROOM/UNIT #
DATE OF BIRTH
/
Month
/
Day
Year
Date
Current Age
Gender
Female
Male
Height (Inches)
Weight (Pounds)
Recent Blood Pressure
Under Physician's Care since (Date)
New Patient
Other
In your opinion, does this resident require skilled nursing?
No
Yes
Other
EXPECTED DATE OF PHYSICAL MOVE IN
/
Month
/
Day
Year
Date
DIAGNOSIS
SEE ATTACHED MAR
DIAGNOSIS
ALLERGIES
SEE ATTACHED MAR
NO KNOWN DRUG ALLERGIES
ALLERGIES
IS THE RESIDENT FREE OF SIGNS/SYMPTOMS OF PULMONARY TB?
YES
NO
DATE OF LAST TB TEST OR LAST CHEST X RAY
/
Month
/
Day
Year
Date
RESIDENT IS FREE OF COMMUNICABLE DISEASES AND CHRONIC CONDITIONS ARE STABLE
YES
NO
RESIDENT MAY HAVE ANNUAL FLU VACCINE PER MANUFACTURER'S GUIDELINES AND AND CDC GUIDELINES.
YES
NO
RESIDENT MAY HAVE COVID-19 VACCINE PER MANUFACTURER'S GUIDELINES AND AND CDC GUIDELINES.
YES
NO
RESIDENT HAS DOCUMENTED PNEUMONIA VACCINE ON FILE. YESATTACHED IN RECORD NOPLEASE ADMINISTER WITH RESIDENT CONSENT
YES, ON RECORD
NO, PLEASE ADMINISTER WITH RESIDENT CONSENT
UNKNOWN, OK TO ADMINISTER WITH CONSENT
Physical Health Status (Add Comments in 'Other')
Auditory Impairment
No
Assistive Device
Visual Impairment
No
Assistive Device
Wears Dentures
No
Assistive Device
Wears Prosthesis
No
Assistive Device
Substance Abuse Issue
No
Assistive Device
Use of Alcohol
No
Assistive Device
Use of Cigarettes
No
Assistive Device
Bowel Impairment
No
Assistive Device
Bladder Impairment
No
Assistive Device
Motor Impairment
No
Assistive Device
Requires Continuous Bed Care
No
Assistive Device
History of Skin Breakdown
No
Assistive Device
Other
Mental Health Status (Add Comments in 'Other')
Confused/Disoriented
No
Inappropriate Behavior
No
Aggressive Behavior
No
Wandering Behavior
No
Sundowning Behavior
No
Difficulty following instructions
No
Depressed
No
Suicidal/Self Abuse
No
Difficulty communicating needs
No
Risk if allowed access to personal hygiene items
No
Requires Continuous Bed Care
No
Other
Capacity for Self Care (Add Comments in 'Other')
Able to Care for All Personal Needs
No
Able to Bathe Self
No
Able to Dress/Groom Self
No
Able to Feed Self
No
Able to Care for Own Toileting Needs
No
Able to Ambulate without Assistance
No
Able to Manage own Finances
No
Needs Constant Medical Supervision
No
Other
Medication Management (Add Comments in 'Other')
Currently Taking Prescribed Medications
No
Able to Administer Own Medications
No
Able to Administer Own Injections
No
Able to Perform Own Glucose Testing
No
Able to Administer Own PRN Meds
No
Able to Administer Own Oxygen
No
Able to Store Own Medications
No
Other
DIET TEXTURE:
REGULAR
MECHANICAL SOFT
CHOPPED
PUREED
LIQUID CONSISTENCY:
THIN/REGULAR
NECTAR THICK
HONEY THICK
PUDDING THICK
DIET TYPE: (PLEASE SELECT ALL THAT APPLY)
RESIDENT MAY SELF-DIRECT
REGULAR DIET
NO CONCENTRATED SWEETS /ADDED SUGAR
NO ADDED SALT
NO DAIRY
NO SHELLFISH
Other
AMBULATORY STATUS: The person is
Ambulatory
Nonambulatory (unable to leave building under emergency conditions, unable or likely unable to physically and mentall respond to a sensory signal, or to an oral instruction relating to fire danger, and persons who depend on mechanical aids such as crutches, walkers, and wheelchairs.
Bedridden
If Nonambulatory, based on Physical Condition
If Nonambulatory, based on Mental Condition
If Nonambulatory, based on Both Physical and Mental Condition
BEDRIDDEN STATUS: A resident who is unable to ambulate or move about independently or with the assistance of an auxillary aid, who also requires assistance in turning and repositioning in bed. If bedridden, check all that describe the nature of the cause, and explain :
Illness
Recovery from Surgery
Other
BEDRIDDEN STATUS: How long is bedridden status expected to persist?
Permanent
Number of Days or Estimated date resident will be no longer badridden
Other
Is the resident receiving hospice care?
No
Yes (Specify the terminal illness)
Other
Physical Health Status: The resident's physical health status is
Good
Fair
Poor
Escort Requirements: When leaving the Community, the resident
Should be escorted by staff due to cognitive impairment
May be dropped off and later picked up by the Community van, leaving him/her unescorted for shopping visits, outings, appointments, etc.
May leave independently with no escort, using public transportation or walking where desired
May drive his/her own vehicle
Mental Health Status
No Cognitive impairment
Mild Cognitive impairment, condition between normal aging and dementia
Dementia: Loss of intellectual functioning (remembering, reasoning, judgement, making decisions) and other cognitive functions sufficient to interfere with and ability to perform activities of daily living or to carry out social or occupational activities. (Residents with a dementia diagnosis will be evaluated for appropriateness in Assisted Living.)
COMMENTS
PHYSICIAN ORDERS
Resident Capable of self-adiminstering medications
No
Resident's medications require crushing? List which in 'Other'
No
Special dietary considerations? List which in 'Other'
No
Code Status: DNR On File
FULL CODE
Advanced age, conditions, and certain medications make the consumption of alcohol a greater health risk than someone without those issues, and not condoned by physician. However, the patient and family may indicate the risk is noted but outweighed by their personal autonomy and preference for quality of life and socialization, over optimal safety.
Alcohol not permitted under any circumstance
Medication Strength, Dose, Route, Frequency has been reviewed on attached MAR photo and approved
Medication orders with changes are attached separately
Other
Medications: Type in this space or you may take photo of current list
Take Photo of MAR
Take Photo 2
Take Photo 3
Take Photo 4
SKIN TEARS
1. APPLY PRESSURE TO STOP BLEEDING, IF PRESENT
2 CLEANSE WOUND WITH NORMAL SALINE OR WOUND CLEANSER
3. GENTLY PAT DRY WITH CLEAN GAUZE
4. UTLIZE COTTON SWAB TO ALIGN WOUND EDGES IF SKIN IS TORN OFF CONTACT MEDICAL PROVIDER FOR ADDITIONAL ORDERS
5. UTILIZE STERI-STRIPS TO SECURE WOUND EDGES, IF EDGES DO NOT STAY RE-ALIGNED
6. COVER WITH NON-ADHERENT DRESSING, CHANGE DAILY AND AS NEEDED FOR SOILAGE OR DISLODGEMENT UNTIL RESOLVED
7. NOTIFY MEDICAL PROVIDER FOR ANY INCREASES IN REDNESS, SWELLING, DRAINAGE, ODOR, OR NOT HEALED IN 14 DAYS.
REDDENED OR EXCORIATED AREA
1. CLEANSE AREA WITH NORMAL SALINE OR WOUND CLEANSER
2 GENTLY PAT DRY WITH CLEAN GAUZE
3. APPLY BARRIER CREAM
4. NOTIFY HEALTH SERVICES DIRECTOR OF AREA UPON DISCOVERY
5. NOTIFY HEALTH SERVICES DIRECTOR AND MD IF AREA BECOMES OPEN, DEVELOPS DRAINIAGE, HAS AN ODOR.
SCRAPES, ABRASIONS, SMALL CUTS (LACERATIONS)
1. CLEANSE AREA WITH NORMAL SALINE OR WOUND CLEANSER
2 GENTLY PAT DRY WITH CLEAN GAUZE
3. COVER WITH NON-ADHERENT DRESSING OR BAND AID
4. CHANGE AS NEEDED FOR SOILING OR IF DISLODGED
5. TREAT UNTIL RESOLVED
6. NOTIFY HSD OF INJURY AND IF AREA INCREASE IN REDNESS, SWELLING, DRAINAGE, FEVER, OR ODOR.
OPEN AREAS, RASHES, BLISTERS
1. NOTIFY HSD AND MEDICAL PROVIDER IMMEDIATELY TO OBTAIN SPECIFIC ORDERS FOR TREATMENT AND/OR HOME HEALTH CONSULT FOR CARE MANAGEMENT OF THE CONDITION.
MEDICATIONS
DIARRHEA: IMMODIUM 2 MG TABS: MAY ADMINISTER 2 TABS BY MOUTH AFTER FIRST EPISODE OF DIARRHEA AND 1 TAB AFTER EACH SUBSEQUENT EPISODE OF DIARRHEA. DO NOT EXCEED 8 TABS IN A 24 HOURS PERIOD. IF THE RESIDENT HAS ADDITIONAL SYMPTOMS SUCH AS ABDOMINAL PAIN, FEVER > 100 ⁰ F, or BLOODY STOOLS NOTIFY MEDICAL PROVIDER IMMEDIATELY. IF DIARRHEA CONTINUES AFTER 8 TABS ARE GIVEN, NOTIFY MEDICAL PROVIDER.
CONSTIPATION: MILK OF MAGNESIA 400MG/5 ML SUSPENSION: MAY ADMINISTER 30 ML BY MOUTH IN NO BOWEL MOVEMENT IN 3 DAYS OR IF THE RESIDENT REPORTS CONSTIPATION AND REQUESTS THE NEED FOR LAXATIVE. IF NOT REPORTED OR NOTED RESULTS IN 12 HOURS NOTIFY MEDICAL PROVIDERS FOR ADDITIONAL ORDERS.
UPSET STOMACH/DYSPEPSIA: MYLANTA: MAY ADMINISTER 30 ML BY MOUTH EVERY 4 HOURS FOR COMPLAINTS OF UPSET STOMACH OR HEARTBURN. NOTIFY MEDICAL PROVIDER IF SYMPTOMS ARE NOT RESOLVED AFTER 4 DOSES OF MEDICATIONS OR IF THE RESIDENT HAS ABDOMINAL PAIN, DARK TARRY (BLOODY) STOOL, OR FEVER > 100⁰ F.
PAIN AND FEVER: ACETAMINOPHEN 325 MG: MAY ADMINISTER 2 TABS (650 MG) BY MONTH AS NEEDED EVERY 6 HOURS FOR COMPLAINTS OF MILD TO MODERATE HEADACHE, MUSCULOSKELETAL PAIN OR OR FEVER > 100⁰ F. DO NOT EXCEED 3000 MG OF ACETAMINOPHEN FROM ALL SOURCES IN A 24-HOUR PERIOD UNLESS OTHERWISE DIRECTED BY A MEDICAL PROVIDER.IF PAIN OR FEVER IS NOT RELIEVED WITHIN 12 HOURS NOTIFY MEDICAL PROVIDER.
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 THE PHARMACY
ALL NEW ORDERS ARE FILLED FOR 31 DAY'S SUPPLY AND CONTINUE FOR 180 DAYS UNLESS OTHERWISE INDICATED IN THE ORDER
MAY UTILIZE GENERIC EQUIVALENTS UNLESS SPECIFIED IN ORDERType option 5
RESIDENTS WITH A DIAGNOSIS OF DIABETES MAY HAVE CBG CHECKED PRN AS DIRECTED BY THE 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 TO ADMINISTER AND STORE MEDICATIONS SAFELY.
NOTIFY THE MEDICAL PROVIDER OF THE FOLLOWING:WHEN THE RESIDENT MISSES ANY SCHEDULED MEDICATION/TREATMENT
COVID-19 TESTING AND VACCINE INFORMATION:
RESIDENT IS FULLY VACCINATED AND DOCUMENATIONS IS ATTACHED
RESIDENT MAY HAVE COVID-19 VACCINE AT NEXT VACCINE CLINIC WITH CONSENT.
COVID-19 TESTING PER COMMUNITY POLICY/STATE MANDATES AND CDC RECOMMENDATIONS FOR SYMPTOMOLOGY AND OUTBREAK TESTING
PCR RESPIRATORY LITE PANEL FOR RESIDENTS WITH SYMPTOMOLOGY OF RESPIRATORY RELATED ILLNESS
HEALTH CARE PROVIDER NAME
NPI #
DEA #
FAX NUMBER
PHONE NUMBER
PROVIDER SIGNATURE
DATE
/
Month
/
Day
Year
Date
Email or Fax number where this form should be returned
example@example.com
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