State of California—Health and Human Services Agency Department of Health Care Services

MEDICAL REVIEW/PROLONGED CARE ASSESSMENT

IC-ICF/DD—ICF/DD-H Semi-Annual Annual
Name / Sex
Male Female / Case number / Birth date
Admission date / Attending physician / Present status
NH IC RC Other
Facility
Address (number, street) / City / ZIP code
Diagnoses / Medications
1. / 1.
2. / 2.
3. / 3.
4. / 4.
5. / 5.
Lab Work / 6.
7.
8.
9.
Diet
Remarks
1) Is the patient involved in school and is treatment plan coordinated with the school? / Yes No
2) Is the patient involved in daily planned activities or any type of learning experience? / Yes No
3) Is patient and staff interaction ongoing? / Yes No
4) Is there any potential? / Yes No
5) Is Plan of Care current? Before admission After admission / Yes No
6) Are individual goals reviewed and/or met/updated? / Yes No
7) Are quarterly notes written timely? / Yes No
8) Are psychological evaluations done? / Yes No
9) Is there QMRP input in the chart and/or whole interdisciplinary team? / Yes No
Every 90 days? / Yes No
Dates of visits / Recommendation
Chart review
Skilled nursing
ICF ______
Interviewer / RCF
ICF/DD
ICF/DD/H

DHCS 6013 A (4/09) Utilization Management Division

INSTRUCTIONS: For ICF/DD/H—Complete all appropriate boxes; others—exclude ICF/DD/H only.
Patient name / Birth date / Sex
Medi-Cal ID number / Admission date / Room number
Facility name / Phone number
( )
Facility address (number, street) / City / ZIP code
Signature of person completing form / Title / Current diagnosis
Patient’s Condition Now / Activities of Daily Living / Communication / Bowel Control
Stable / Mark either—Independent (1), / Able to make needs known / Occasionally involuntary
Unstable / Assist. with mechanical device (A1) / Speaks no English / Involuntary
Terminal / Assist. with a person (A) / Can write, not speak / Colostomy/lleostomy
Assist. by person and device (A3) / Cannot speak or write, but seems to / Self-care
Rehabilitation Potential / or Total Dependent (D) / comprehend / Bladder Control
Good / Walking / Aphasic, partial / Occasionally incontinent
Fair / Transferring / Aphasic, complete / Incontinent
Poor / Wheeling / Catheter
Complete this section for ICF/DD/H only / Bathing / Wound Care—Dressings / Bowel-Bladder Training—Date
Program Provided / Dressing / Dry sterile dressing
Frequency: 1—Once a day; 2—BID; / Grooming / Open, draining / Feeding
3—TID; 4—2; or more per week; 5—weekly / Toileting / Sterile/medicated dressing / Feeding program date
Range of motion / Feeds self with assistive device
Preventive/corrective positioning / Visual / Diabetic Care / Needs partial help in feeding
Ambulation skills / No apparent handicap / Inability to manage diabetic condition / Needs to be fed
Transfer skills / Correctable vision w/glasses / Well-regulated by diet only / N-G tube
Grooming/dressing skills / Severe visual impairment / Well-regulated with medication / Gastrostomy
Mental stimulation / Legally or totally blind / Uncontrolled / Parenteral
Communication skills / Urine testing / Supplemental feedings
Bladder retraining / Auditory
Bowel retraining / No apparent hearing problem / Rehabilitation and M.D. Orders / Current Medications
Feeding skills / Mild hearing problem / Physical therapy / Antibiotics
Social behavior / Wears hearing aid / Occupational therapy / Cardiac drugs
Aggression / Deafness, corrected by aid / Speech therapy / Diuretics
Self-injurious / Deafness, not corrected / Anticoagulants
Smearing / Rehabilitative Nursing Program / Chemotherapy
Destruction of property / Mental and Behavioral Status / Other Special Needs/Problems / Insulin
Running or wandering away / Receiving psychiatric care x3 / Amputee—location / Tranquilizers
Temper tantrums or emotional outbursts / Alert and oriented x3 / Braces/cast / Hypnotics
Plan of Care / Disoriented / Seizures / Narcotics
Individual goals are met and updated? / Confused / Paralysis/area / Oral hypoglycemic
Yes No / Wanderer / Joint motion/pain/swelling
Is the plan of care complete and updated? / Noisy, yells/agitated / Inhalation/oxygen therapy / Decubitus Ulcer
Yes No / Aggressive / Tracheostomy care / None or healed
Degree of Retardation / Combative / Suctioning / Stage I—red/inflamed area
Mild / Other antisocial behavior / Multiple injections or IVs / Stage II—superficial skin break
Moderate / Withdrawn / Fluid retention / w/red surrounding
Severe / Comatose / Isolation techniques / Stage III
Profound / Follows simple instructions / Contractures / Stage IV
DO NOT COMPLETE BELOW THIS LINE—STATE USE ONLY
General Appearance of Patient / Notes:
Yes No / Yes No
1. Clean / Physician’s progress notes timely?
2. Hair clean and neat / Medications reviewed and signed timely?
3. Shaved / Date of tuberculin testing or chest X-ray:______
4. Fingernails clean/trimmed
5. Toenails clean/trimmed / Date of last physical
6. Dressed appropriately
7. Out of bed
8. Restrained / Significant laboratory results
9. Transportation
10 Equipment / (For additional comments, use the back.)
Yes No Yes No Yes No
Chart review Patient interview Prolonged care / Reviewer’s signature / Date

DHCS 6013 A (4/09) Utilization Management Division