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ADULT CARE HOME PERSONAL CARE PHYSICIAN AUTHORIZATION AND (North Carolina)

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DMA-3050-R
ADULT CARE HOME
PERSONAL CARE PHYSICIAN AUTHORIZATION AND CARE PLAN
Assessment Date: ___/___/___
Reassessment Date: ___/___/___
Significant Change: ___/___/___
RESIDENT INFORMATION
(Please Print or Type)
RESIDENT_________________________________ SEX (M/F) ______ DOB _____/_____/_____MEDICAID ID NO__________________
FACILITY_________________________________________________________________________________________________________
ADDRESS_________________________________________________________________________________________________________
_____________________________________________________ Phone __________________ Provider No. _________________________
DATE OF MOST RECENT EXAMINATION BY PRIMARY CARE PHYSICIAN _____/_____/_____
ASSESSMENT
1. MEDICATIONS — Identify and report all medications, including non-prescription meds, that will continue upon admission:
Name
Dose
Frequency
Route
( X ) If Self-Administered
2. MENTAL HEALTH AND SOCIAL HISTORY: (If checked, explain in "Social/ Mental Health History" section)
Wandering
Verbally Abusive
Physically Abusive
Resists Cure
Suicidal
Homicidal
Disruptive Behavior/Socially Inappropriate
Injurious to:
Self Others Property
Is the resident currently receiving
medications for mental
illness/behavior?
Yes No
Is there a history of:
Substance Abuse
Developmental Disabilities (DD)
Mental Illness
Is the resident currently receiving Mental Health, DD,
or Substance Abuse Services (SAS)?
Yes No
Social/Mental Health History:
DMA-3050-R
Resident _________________________
3. AMBULATION/ LOCOMOTION: No Problems Limited Ability Ambulatory w/ Aide or Device(s) Non-Ambulatory
Device(s) Needed ______________________________________________________________________________________
Has device(s): Does not use Needs repair or replacement
4. UPPER EXTREMITIES: No Problems Limited Range of Motion Limited Strength Limited Eye-Hand Coordination
Specifically affected joint(s)_____________________________________________ Right Left Bilateral
Other impairment, specify
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Device(s) Needed _______________________________ Has device(s): Does not use Needs repair or replacement
5. NUTRITION: Oral Tube (Type)________________________________ Height____________Weight ___________
Dietary Restrictions:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Device(s) Needed _______________________________________________________________________________________
Has Device(s): Does not use Needs repair or replacement
6. RESPIRATION: Normal Well-Established Tracheostomy Oxygen Shortness of Breath
Device(s) Needed: ___________________________________________ Has device(s): Does not use Needs repair or replacement
7. SKIN: Normal Pressure Areas Decubiti Other _________________________________________________________
Skin Care Needs _________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
8. BOWEL: Normal Occasional Incontinence (less than daily) Daily Incontinence
Ostomy: Type _____________________________________ Self-care: YES NO
9. BLADDER: Normal Occasional Incontinence (less than daily) Daily Incontinence
Catheter: Type: _____________________________________ Self-care: YES NO
10. ORIENTATION: Oriented Sometimes Disoriented Always Disoriented
11. MEMORY: Adequate Forgetful-Needs Reminders Significant Loss - Must Be Directed
12. VISION: Adequate for Daily Activities Limited (Sees Large Objects) Very Limited (Blind); Explain ________________
Uses: Glasses Contact Lens Needs repair or replacement
Comments ___________________________________________________________________________________________________
_____________________________________________________________________________________________________________
13. HEARING: Adequate for Daily Activities Hears Loud Sounds/Voices Very Limited (Deaf); Explain: _______________
Uses Hearing Aid(s) Needs repair or replacement
Comments: ___________________________________________________________________________________________________
14. SPEECH/COMMUNICATION METHOD: Normal Slurred Weak Other Impediment No Speech
Gestures Sign Language Writing Foreign Language Only________________________ Other None
Assistive Device(s) (Type:____________________________) Has device(s): Does not use Needs repair or replacement
DMA-3050-R
Resident: ____________________________
CARE PLAN
15. IF THE ASSESSMENT INDICATES THE RESIDENT HAS MEDICALLY RELATED PERSONAL CARE NEEDS REQUIRING
ASSISTANCE, SHOW THE PLAN FOR PROVIDING CARE. CHECK OFF THE DAYS OF THE WEEK EACH ADL TASK IS
PERFORMED AND RATE EACH ADL TASK BASED ON THE FOLLOWING PERFORMANCE CODES: O - INDEPENDENT,
1 - SUPERVISION, 2 - LIMITED ASSISTANCE, 3 - EXTENSIVE ASSISTANCE, 4 - TOTALLY DEPENDENT. (PLEASE REFER TO
YOUR ADULT CARE HOME PROGRAM MANUAL FOR MORE DETAIL ON EACH PERFORMANCE CODE.)
ACTIVITIES OF DAILY LIVING (ADL)
DESCRIBE THE SPECIFIC TYPE OF ASSISTANCE NEEDED BY THE RESIDENT
AND PROVIDED BY STAFF NEXT TO EACH ADL:
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
PERFORMANCE
CODE
EATING
TOILETING
AMBULATION/LOCOMATION
BATHING
DRESSING
GROOMING/PERSONAL HYGIENE
TRANSFERRING
OTHER: (Include Licensed Health Professional Support (LHPS) Personal Care Tasks, as listed in Rule 42C .3703, and any other special care
needs.)
ASSESSOR CERTIFICATION
I certify that I have completed the above assessment of the resident’s condition. I found the resident needs personal care services due to the
resident’s medical condition. I have developed the care plan to meet those needs.
Resident/responsible party has received education on Medical Care Decisions and Advance Directives prior to admission.
___________________________________ ________________________________________ ____________________
Name Signature Date
PHYSICIAN AUTHORIZATION
I certify that the resident is under my care and has a medical diagnosis with associated physical/mental limitations warranting the provision of the
personal care services in the above care plan.
The resident may take therapeutic leave as needed.
___________________________________ ________________________________________ ____________________
Name Signature Date
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ADULT CARE HOME PERSONAL CARE PHYSICIAN AUTHORIZATION AND (North Carolina)

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Completed 8 December 2021

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