INTERNATIONAL MENTAL HEALTH NETWORK, LTD.
P.O. Box 578
Poway, CA 92074-0578
Phone: (858) 486-9745
Fax: (858) 486-9760
E-mail: nac01@juno.com
A package of 10 test booklets and 50 answer sheets
available for $25 from IMH-Network: (858) 486-9745
Test Description
Return to the Index
NOTE: ONLY A PORTION OF PROFILE AVAILABLE DUE TO LENGTH
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S A M P L E P R O F I L E
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LONG TERM CARE HEALTH ASSESSMENT INVENTORY
International Mental Health Network, Ltd.
TC: 7145
FACILITY ID: 31
PATIENT ID: 3112345
SOCIAL SECURITY NUMBER: 555-44-3333
LAST NAME: Bloomfield
FIRST NAME: Janice
GENDER: Female
AGE: 65
RACE: White
HIGHEST GRADE COMPLETED: 12
MARITAL STATUS: Widowed
OCCUPATION: Real Estate
CURRENT EMPLOYMENT STATUS: Retired
INPATIENT/OUTPATIENT: Inpatient
NUMBER OF INPATIENT ADMISSIONS: 1
NUMBER OF OUTPATIENT ADMISSIONS:
DATE OF LAST DISCHARGE:
YEARS OF ALCOHOL USE: 15
YEARS OF DRUG USE: 0
SUBSTANCES USED LAST 2 YEARS: None
SOURCE OF REFERRAL: Family
FINANCIAL CLASS: Medicare
DATE OF LAST PHYSICAL EXAM: 04/05/97
ADMISSION DATE: 05/01/98
DATE OF TESTING: 05/05/98
This clinical profile is a confidential assessment report intended for use
by professional staff only. Its purpose is to provide clinicians with a
comprehensive clinical picture of each patient under their care, and to help
maximize therapeutic effectiveness through careful assessment, treatment
planning, relapse prevention, and aftercare. Recommendations made in this
profile do not imply that existing clinical approaches should be replaced or
modified. Their intent is to further promote individualization of patient
treatment planning, multidisciplinary approach to treatment of each patient,
patient's participation in own recovery process, and continuous monitoring
and reassessment of the therapeutic process for mutual benefit of both the
patient and clinical staff. Statements in this profile are hypotheses for
further consideration in combination with other clinical factors utilized
in therapy. This profile is intended for use by a multidisciplinary clinical
team.
________________________________ _______________ ______________
Reviewing Professional Title Date
Copyright (C) 1997, IMH-Network
_______________________________________________________________________________
INSTRUCTIONS
SYMPTOM DISTRIBUTION INDEX
- clinician's assessment is performed for all symptoms at index
levels "mild" or higher; to be monitored at regular intervals;
SYMPTOM ACUITY INDEX
- clinician's assessment is performed for all symptoms at index
levels "mild" or higher; to be monitored at regular intervals;
SYMPTOM SEVERITY INDEX (PAST, PRESENT, AND RESIDUAL)
- clinician's assessment is performed for all symptoms at index
levels "mild" or higher; to be monitored at regular intervals;
FUNCTIONALITY ASSESSMENT AND PATIENT'S REHABILITATIVE RESPONSE
- clinician's assessment is performed for all symptoms at index
levels "moderate" or higher; to be monitored at regular intervals;
ASSESSMENT OF PAIN EXPERIENCE
- clinician's assessment is performed for all symptoms at index
levels "mild" or higher; to be monitored at regular intervals;
ASSESSMENT OF HEALTH RISK INDEX
- clinician's assessment is performed for all symptoms at index
levels "moderate" or higher; occasional monitoring is recommended;
ASSESSMENT OF SYMPTOMS OF ABUSE
- clinician's assessment is performed for all symptoms at index
levels "moderate" or higher and when there is no clear indication
that symptomatic injuries are either self-inflicted, a result of
physical confrontation due to patient's explosiveness and violent
behavior, or a consequence of a specific physical impairment and/or
handicap where self-injury is likely to occur;
ASSESSMENT OF SYMPTOM/EVENT COINCIDENCE
- clinician's assessment is performed for all symptoms at index
levels "moderate" or higher; occasional monitoring is recommended;
ASSESSMENT OF SUBSTANCE ABUSE INDEX
- clinician's assessment is performed for all symptoms at index
levels "mild" or higher; post-treatment monitoring is recommended;
ASSESSMENT OF PATIENT'S CURRENT FUNCTIONING
- clinician's assessment is performed for all patients and repeated
at regular intervals; post-treatment monitoring is recommended;
ICD-9 / DRG CODE TABLE
- for all symptoms presented by a patient, code table provides
the following: ICD-9 diagnostic codes
MDC - major diagnostic categories
DRG - single or multiple applicable DRGs
MVRW INDEX - mean value of HCFA DRG relative
weights for all applicable DRGs
BRIEF HEALTH HISTORY
- intended for initial collection of patient's medical historical
data, or when more comprehensive H&P is not immediately required;
SPECIFIC SYMPTOMS MONITORING SCHEDULES
- monitoring schedules are automatically generated by MSI for each
group of symptoms where index levels are "moderate" or higher;
_______________________________________________________________________________
Patient ID: 3112345 07/26/95
CURRENT SYMPTOM DISTRIBUTION INDEX
SYSTEMS |RAW| |RANGE | FLAGS
------------------+---+-------+-------+-------+-------+--------+------+-------
Dermatological| 10|**** |Low |
Head| 10|**** |Low |
Ophthalmological| 20|******** |Mild |
Ears| 20|******** |Mild |
Nose| 30|************ |Mild |
Dental| 10|**** |Low |
Mouth| 10|**** |Low |
Throat| 0| |None |
Neck| 10|**** |Low |
Breasts| 20|******** |Mild |
Pulmonary| 0| |None |
Cardiological| 10|**** |Low |
Hematological| 20|******** |Mild |
Gastrointestinal| 10|**** |Low |
Genitourinary| 10|**** |Low |
Gynecological| 30|************ |Mild |
Musculoskeletal| 40|**************** |Medium|
Neurological| 10|**** |Low |
Endocrine| 10|**** |Low |
Psychiatric| 40|**************** |Medium|
+------------------+---+-------+-------+-------+-------+--------+------+-------
COPYRIGHT (C) 1997 IMH-Network
PAST SYMPTOM DISTRIBUTION INDEX
SYSTEMS |RAW| |RANGE | FLAGS
------------------+---+-------+-------+-------+-------+--------+------+-------
Dermatological| 20|******** |Mild |
Head| 30|************ |Mild |
Ophthalmological| 20|******** |Mild |
Ears| 0| |None |
Nose| 0| |None |
Dental| 0| |None |
Mouth| 10|**** |Low |
Throat| 20|******** |Mild |
Neck| 0| |None |
Breasts| 20|******** |Mild |
Pulmonary| 0| |None |
Cardiological| 10|**** |Low |
Hematological| 20|******** |Mild |
Gastrointestinal| 0| |None |
Genitourinary| 30|************ |Mild |
Gynecological| 0| |None |
Musculoskeletal| 0| |None |
Neurological| 20|******** |Mild |
Endocrine| 10|**** |Low |
Psychiatric| 0| |None |
+------------------+---+-------+-------+-------+-------+--------+------+-------
COPYRIGHT (C) 1997 IMH-Network
_______________________________________________________________________________
Patient ID: 3112345 07/26/95
RESIDUAL SYMPTOM DISTRIBUTION INDEX
SYSTEMS |RAW| |RANGE | FLAGS
------------------+---+-------+-------+-------+-------+--------+------+-------
Dermatological| 20|******** |Mild |
Head| 10|**** |Low |
Ophthalmological| 0| |None |
Ears| 10|**** |Low |
Nose| 0| |None |
Dental| 20|******** |Mild |
Mouth| 10|**** |Low |
Throat| 0| |None |
Neck| 30|************ |Mild |
Breasts| 10|**** |Low |
Pulmonary| 10|**** |Low |
Cardiological| 0| |None |
Hematological| 10|**** |Low |
Gastrointestinal| 20|******** |Mild |
Genitourinary| 20|******** |Mild |
Gynecological| 10|**** |Low |
Musculoskeletal| 10|**** |Low |
Neurological| 30|************ |Mild |
Endocrine| 10|**** |Low |
Psychiatric| 0| |None |
------------------+---+-------+-------+-------+-------+--------+------+-------+
- There is an indication of medical emergency, (y/n) ............ ________
- Focused examination recommended, (y/n) ........................ ________
- Comprehensive examination recommended, (y/n) .................. ________
- Interval for reevaluation: ______________________________________________
- Regular monitoring required, (y/n) ____ at intervals of _________________
- Approximate stabilization period: _______________________________________
- Possible causes: ________________________________________________________
- Aggravating factors: __________________________________________________
- Ameliorating factors: __________________________________________________
- Recommended action(s): __________________________________________________
- Pharmacological treatment required, (y/n) ..................... ________
- Medication regimen(s): __________________________________________________
- Clinical staff required: ________________________________________________
- Referral to an outside agency is required, (y/n) .............. ________
_______________________________ _______________
Clinical staff Date
COPYRIGHT (C) 1997 IMH-Network
_______________________________________________________________________________
Patient ID: 3112345 07/26/95
SYMPTOM ACUITY INDEX
|TCS| |RANGE | FLAGS
--------------+---+-----+----+----------+----------+-----------+------+-------
Current| 17|******* |Mild |
Past| 15|****** |Low |
Residual| 9|*** |Low |
--------------+---+-----+----+----------+----------+-----------+------+-------+
CLINICIAN'S ASSESSMENT OF LEVEL OF ACUITY
Condition presents medical emergency _____________________________________
Potential for exarcebation : _____________________________________________
Potential for organ(s) failure: __________________________________________
Recommended intervention(s): _____________________________________________
Clinical staff required: _________________________________________________
Appropriateness of admission: ____________________________________________
Availability of resources: _______________________________________________
Impact upon extended treatment: __________________________________________
Need for referral to: ____________________________________________________
Secondary referral resource: _____________________________________________
Assistance with referral/transportation required: ________________________
Readmission recommended after a period of: _______________________________
Criteria for admission/readmission: ______________________________________
Comments: ________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
___________________________ _______________
Clinical staff Date
COPYRIGHT (C) 1997 IMH-Network
_______________________________________________________________________________
Patient ID: 3112345 07/26/95
CURRENT SYMPTOM SEVERITY INDEX
SYSTEMS |TCS| |RANGE | FLAGS
------------------+---+-----+---+---------+---------+----------+------+-------
Dermatological| 3|* |Low |
Head| 3|* |Low |
Ophthalmological| 24|********* |Mild |
Ears| 21|******** |Mild |
Nose| 22|******** |Mild |
Dental| 11|**** |Low |
Mouth| 16|****** |Mild |
Throat| 0| |None |
Neck| 12|**** |Low |
Breasts| 17|****** |Mild |
Pulmonary| 0| |None |
Cardiological| 16|****** |Mild |
Hematological| 24|********* |Mild |
Gastrointestinal| 3|* |Low |
Genitourinary| 8|*** |Low |
Gynecological| 18|******* |Mild |
Musculoskeletal| 37|************** |Medium|
Neurological| 16|****** |Mild |
Endocrine| 14|***** |Low |
Psychiatric| 45|****************** |Medium|
+------------------+---+-----+---+---------+---------+----------+------+-------+
CLINICIAN'S ASSESSMENT OF CURRENT LEVEL OF SYMPTOM SEVERITY
Major problem content: ___________________________________________________
Associated problems: _____________________________________________________
Predominant symptoms: ____________________________________________________
Disease/symptom duration: ________________________________________________
Severity od disablement: _________________________________________________
Initial level of severity: _______________________________________________
Change experienced (improvement/deterioration): __________________________
Day-to-day variability in severity: ______________________________________
Change in the rate of change during treatment: ___________________________
Number of symptom sites: _________________________________________________
Number of hours per week of distress: ____________________________________
Daily stress impact: _____________________________________________________
History of treatment compliance: _________________________________________
Extent of clinical risk: _________________________________________________
Potential for multiple organ failure: ____________________________________
COPYRIGHT (C) 1997 IMH-Network
_______________________________________________________________________________
Patient ID: 3112345 07/26/95
PAST SYMPTOM SEVERITY INDEX
SYSTEMS |TCS| |RANGE | FLAGS
------------------+---+-----+---+---------+---------+----------+------+-------
Dermatological| 25|********** |Medium|
Head| 38|*************** |Medium|
Ophthalmological| 31|************ |Medium|
Ears| 0| |None |
Nose| 0| |None |
Dental| 0| |None |
Mouth| 6|** |Low |
Throat| 20|******** |Mild |
Neck| 0| |None |
Breasts| 17|****** |Mild |
Pulmonary| 0| |None |
Cardiological| 12|**** |Low |
Hematological| 20|******** |Mild |
Gastrointestinal| 0| |None |
Genitourinary| 26|********** |Medium|
Gynecological| 0| |None |
Musculoskeletal| 0| |None |
Neurological| 10|**** |Low |
Endocrine| 7|** |Low |
Psychiatric| 0| |None |
------------------+---+-----+---+---------+---------+----------+------+-------+
CLINICIAN'S ASSESSMENT OF LEVEL OF SEVERITY OF PAST SYMPTOMS
Age at onset of symptoms: ____ Sudden or gradual onset: _______________
Major self-reported complaints: __________________________________________
Major elicited complaints: _______________________________________________
Average duration of unaided functioning: _________________________________
Quality of life before onset of symptoms: ________________________________
Quality of life after onset of symptoms: _________________________________
Number of inpatient treatments for same/similar symptoms: ________________
Number of outpatient treatments for same/similar symptoms: _______________
Effectiveness of previous treatments: ____________________________________
Impact upon rest activities: _____________________________________________
Estimated level of severity: _____________________________________________
Type of adaptation to distress: __________________________________________
COPYRIGHT (C) 1997 IMH-Network
_______________________________________________________________________________
Patient ID: 3112345 07/26/95
RESIDUAL SYMPTOM SEVERITY INDEX
SYSTEMS |TCS| |RANGE | FLAGS
------------------+---+-----+---+---------+---------+----------+------+-------
Dermatological| 18|******* |Mild |
Head| 7|** |Low |
Ophthalmological| 0| |None |
Ears| 6|** |Low |
Nose| 0| |None |
Dental| 18|******* |Mild |
Mouth| 3|* |Low |
Throat| 0| |None |
Neck| 33|************* |Medium|
Breasts| 14|***** |Low |
Pulmonary| 5|** |Low |
Cardiological| 0| |None |
Hematological| 6|** |Low |
Gastrointestinal| 25|********** |Medium|
Genitourinary| 20|******** |Mild |
Gynecological| 14|***** |Low |
Musculoskeletal| 17|****** |Mild |
Neurological| 23|********* |Mild |
Endocrine| 14|***** |Low |
Psychiatric| 0| |None |
+------------------+---+-----+---+---------+---------+----------+------+-------+
CLINICIAN'S ASSESSMENT OF SEVERITY OF RESIDUAL SYMPTOMS
Average duration of symptoms since initial onset: ________________________
Degree of disabling effect on patient: ___________________________________
Subjective time experience: ______________________________________________
Current state of patient's mental health: _______________________________
Subjectivity of symptoms: ________________________________________________
Quality of life under distress: __________________________________________
Degree of adaptation to distress: ________________________________________
Effects of long term illness/symptoms: ___________________________________
Level of patient's knowledge about illness, its process and rehabilitation:
__________________________________________________________________________
Frequency of "medication on" periods: ____________________________________
Frequency of "medication off" periods: ___________________________________
Symptoms cessation rate (spontaneous/periodic): __________________________
Perceived social/familial support: _______________________________________
COPYRIGHT (C) 1997 IMH-Network
_______________________________________________________________________________
Patient ID: 3112345 07/26/95
FUNCTIONAL IMPAIRMENT INDEX
|TCS| |RANGE | FLAGS
--------------+---+-----+----+----------+----------+-----------+------+-------
VISUAL| | | |
Current| 36|*************** |Medium|
Past| 28|************ |Medium|
Residual| 26|*********** |Medium|
--------------+---+-----+----+----------+----------+-----------+------+-------
AUDITORY| | | |
Current| 22|********* |Mild |
Past| 16|******* |Mild |
Residual| 16|******* |Mild |
--------------+---+-----+----+----------+----------+-----------+------+-------
VOCAL| | | |
Current| 19|******** |Mild |
Past| 16|******* |Mild |
Residual| 16|******* |Mild |
--------------+---+-----+----+----------+----------+-----------+------+-------
SMELL| | | |
Current| 28|************ |Medium|
Past| 22|********* |Mild |
Residual| 22|********* |Mild |
--------------+---+-----+----+----------+----------+-----------+------+-------
COPYRIGHT (C) 1997 IMH-Network
FUNCTIONAL IMPAIRMENT INDEX
|TCS| |RANGE | FLAGS
--------------+---+-----+----+----------+----------+-----------+------+-------
TACTILE| | | |
Current| 10|**** |Low |
Past| 10|**** |Low |
Residual| 8|*** |Low |
--------------+---+-----+----+----------+----------+-----------+------+-------
LOCOMOTION| | | |
Current| 22|********* |Mild |
Past| 17|******* |Mild |
Residual| 12|***** |Low |
--------------+---+-----+----+----------+----------+-----------+------+-------
DEXTERITY| | | |
Current| 22|********* |Mild |
Past| 15|****** |Low |
Residual| 9|*** |Low |
--------------+---+-----+----+----------+----------+-----------+------+-------
SELF-CARE| | | |
Current| 20|******** |Mild |
Past| 8|*** |Low |
Residual| 8|*** |Low |
--------------+---+-----+----+----------+----------+-----------+------+-------
COPYRIGHT (C) 1997 IMH-Network
_______________________________________________________________________________
Patient ID: 3112345 07/26/95
FUNCTIONAL IMPAIRMENT INDEX
|TCS| |RANGE | FLAGS
--------------+---+-----+----+----------+----------+-----------+------+-------
ADL| | | |
Current| 19|******** |Mild |
Past| 10|**** |Low |
Residual| 6|** |Low |
--------------+---+-----+----+----------+----------+-----------+------+-------
FAMILIAL| | | |
Current| 23|********** |Mild |
Past| 16|******* |Mild |
Residual| 12|***** |Low |
--------------+---+-----+----+----------+----------+-----------+------+-------
INTERPERSONAL| | | |
Current| 26|*********** |Medium|
Past| 15|****** |Low |
Residual| 13|***** |Low |
--------------+---+-----+----+----------+----------+-----------+------+-------
SOCIAL| | | |
Current| 20|******** |Mild |
Past| 8|*** |Low |
Residual| 11|**** |Low |
--------------+---+-----+----+----------+----------+-----------+------+-------
COPYRIGHT (C) 1997 IMH-Network
FUNCTIONAL IMPAIRMENT INDEX
|TCS| |RANGE | FLAGS
--------------+---+-----+----+----------+----------+-----------+------+-------
OCCUPATIONAL| | | |
Current| 19|******** |Mild |
Past| 9|*** |Low |
Residual| 4|* |Low |
--------------+---+-----+----+----------+----------+-----------+------+-------
TEMPORARY| | | |
Current| 16|******* |Mild |
Past| 8|*** |Low |
Residual| 4|* |Low |
--------------+---+-----+----+----------+----------+-----------+------+-------
LONG TERM| | | |
Current| 20|******** |Mild |
Past| 12|***** |Low |
Residual| 6|** |Low |
--------------+---+-----+----+----------+----------+-----------+------+-------
PERMANENT| | | |
Current| 29|************ |Medium|
Past| 18|******* |Mild |
Residual| 11|**** |Low |
--------------+---+-----+----+----------+----------+-----------+------+-------
COPYRIGHT (C) 1997 IMH-Network
_______________________________________________________________________________
Patient ID: 3112345 07/26/95
FUNCTIONAL IMPAIRMENT INDEX
|TCS| |RANGE | FLAGS
--------------+---+-----+----+----------+----------+-----------+------+-------
HIGH IMPACT| | | |
Current| 17|******* |Mild |
Past| 14|****** |Low |
Residual| 5|** |Low |
--------------+---+-----+----+----------+----------+-----------+------+-------
FUNCTIONALITY ASSESSMENT SUMMARY
- Severity of impairment: __________________________________________________
- Immediacy of need for treatment: _________________________________________
- Availability of treatment: _______________________________________________
- Daily adaptation to symptoms: ____________________________________________
- Activities helping adaptation: ___________________________________________
- Need for continuity of treatment: ________________________________________
- Short-term goals: ________________________________________________________
- Assessment criteria: _____________________________________________________
- Adequacy/effectiveness of treatment: _____________________________________
- Reevaluation schedule: ___________________________________________________
- Extent of client's participation: ________________________________________
- Clinical personnel required: _____________________________________________
- Financial resources available/required: __________________________________
- Patient rights issues: ___________________________________________________
- Potential for relapse: ___________________________________________________
- Relapse prevention: ______________________________________________________
- Long-term goals: _________________________________________________________
- Ambulatory aids: _________________________________________________________
RESOURCES TO BE UTILIZED IN REHABILITATION:
____ Adult education ____ Mental health
____ Day programs ____ Support groups
____ Elder services ____ Respiratory aids
____ Employment and training ____ Speech rehabilitation
____ Equipment ____ Occupational therapy
____ Extended care ____ Physical therapy
____ Financial assistance ____ Recreational therapy
____ Food/meals ____ Mental health program
____ Assistance with utilities ____ Substance abuse program
____ Health insurance ____ Nursing home
____ Health education programs ____ Nutritional counseling
____ Home care ____ Nutritional therapy
____ Homemaker ____ Emergency response system
____ Hospice ____ Protective services
____ Housing ____ Victims assistance
____ Legal services ____ Volunteer program
____ Weight management ____ Cosmetic counseling
____ Special assessment ____ Ambulatory aids
____ Other: _________________________________________________________
_________________________________________________________
_________________________________________________________
ASSESSMENT OF PATIENT'S REHABILITATIVE RESPONSE
- Factors influencing positive response to rehabilitation:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
- Factors influencing negative response to rehabilitation:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
- Clinical considerations and interventions:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
- Goals of rehabilitation and expected outcomes:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
- Limitations, adaptations, modifications:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
- Expected duration of achievements:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_____________________________ _________________
Clinical staff Date
COPYRIGHT (C) 1997 IMH-Network
_______________________________________________________________________________
Patient ID: 3112345 07/26/95
PAIN INDEX
|TCS| |RANGE | FLAGS
--------------+---+-----+----+----------+----------+-----------+------+-------
Acute| 24|********** |Mild |
Residual| 31|************* |Medium|
--------------+---+-----+----+----------+----------+-----------+------+-------+
ASSESSMENT OF PAIN EXPERIENCE
- type of pain reported by client:
____ acute pain
____ acute recurrent
____ chronic (residual)
____ chronic progressive
____ induced (describe): __________________________________
- Identifiable physical pathology/abnormality, (yes/no) _____
if yes, describe:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
- pain-specific physiological response(s), (yes/no): _____
if yes, describe:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
- pain-specific behaviors: _____ verbalization
_____ vocalization
_____ motor activity
_____ facial expressions
_____ gestures
_____ specific posturing
_____ helplessness
- psychological factors contributing to pain experience, (describe):
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________ _____________
Clinical staff Date
COPYRIGHT (C) 1997 IMH-Network
_______________________________________________________________________________
Patient ID: 3112345 07/26/95
HEALTH RISK INDEX
|TCS| |RANGE | FLAGS
--------------+---+-----+----+----------+----------+-----------+------+-------
DISTAL| | | |
Current| 30|************* |Medium|
Past| 18|******* |Mild |
Residual| 13|***** |Low |
+--------------+---+-----+----+----------+----------+-----------+------+-------+
PROXIMAL| | | |
Current| 21|********* |Mild |
Past| 14|****** |Low |
Residual| 12|***** |Low |
+--------------+---+-----+----+----------+----------+-----------+------+-------+
CLINICIAN'S ASSESSMENT OF HEALTH RISK
Client's condition(s) presents health risk to others such as:
spouse ______
children ______
other members of family ______
caretaker ______
social contacts ______
business associates ______
general public ______
Client's condition/behaviors presenting health risk to self:
smoking ______
drinking ______
drugs use/abuse ______
unprotected sex ______
type of work performed ______
exposure to chemicals/environment ______
type of recreational activities ______
aggressive/violent behaviors ______
falling ______
loss of sense(s) ______
loss of memory ______
loss of coordination ______
loss of consciousness ______
organ(s) failure ______
other (describe) ___________________________________
Recommended approach: ____________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
COPYRIGHT (C) 1997 IMH-Network
_______________________________________________________________________________
Patient ID: 3112345 07/26/95
Ñ Ñ SYMPTOMS OF ABUSE Ñ Ñ
|TCS| |RANGE | FLAGS
--------------+---+-----+----+----------+----------+-----------+------+-------
Current| 16|********************* |Medium|
Past| 2| |Low |
Residual| 0| |None |
--------------+---+-----+----+----------+----------+-----------+------+-------+
SYMPTOMATIC INJURY ASSESSMENT - DEPENDENT ADULT
____ black eyes
____ bite marks
____ cigarette burns
____ broken finger nails
____ bruises inside wrist(s)
____ unkept hair, nails and appearance
____ scars from unsutured cuts
____ wrist cut hesitation marks
____ finger marks (bruises) on arms, above elbows,
____ bruises, red and swollen areas about the face,
____ belt marks and snap marks from towels
____ lack of makeup or spotty makeup attempting to hide bruises
____ finger nail scratches on the face and neck areas
____ cuts, contusions and lumps on the scalp caused by strikes
____ bruises and lacerations on forearms, along ulnar plane
____ single biceps brachii bruise caused by thumb pressure and
2-4 opposing bruises along triceps tendon or triceps muscles
____ abrasions, redness and/or swelling about the knuckles
____ small cuts, scratches or nicks on the fingers and backs of hands
____ bruises about the body - back, kidney areas or thighs
SYMPTOMATIC INJURY ASSESSMENT - ELDERLY
____ finger marks on arms or inside wrists
____ scratches about the face and neck
____ unattended or improperly treated injuries
____ bed sores
____ ants or other insects on person or clothing
____ dirty clothing, soiled, stained, torn or bloody underclothing
____ uncut hair and nails
____ signs of poor hygiene and sanitation
____ symptoms of malnutrition
____ bruises
SYMPTOMATIC INJURY ASSESSMENT - CHILD
____ redness, swelling, lumps, bruises on face, head and body
____ hand (slap) marks about face and body
____ bruises on arms, thumb and finger marks above elbow
____ blunt object bruises and abrasions
____ belt marks, marks caused by paddles, ladles, or boards about back
and legs under clothing line
____ cigarette or other burn marks
____ cuts inside lips from strike contact with teeth
____ neck injuries from shaking
____ injuries, abrasions, and contusions caused by throwing, or falling
____ symptoms of malnutrition, diaper rash, dirty clothing or blankets
____ broken bones, healed fractures, open or unattended sores and cuts
COPYRIGHT (C) 1997 IMH-Network
_______________________________________________________________________________
Patient ID: 3112345 07/26/95
SYMPTOM/EVENT COINCIDENCE
|TCS| |RANGE | FLAGS
--------------+---+-----+----+----------+----------+-----------+------+-------+
Current| 53|*********************** |High | ®
--------------+---+-----+----+----------+----------+-----------+------+-------+
CLINICIAN'S ASSESSMENT OF SYMPTOM/EVENT COINCIDENCE
(yes/no)
______ During last 4-6 weeks patient's symptoms have exacerbated
______ Patient is a regular smoker
______ Appearance/exacerbation of symptoms coincided with stressful
events in patient's life
______ Patient consumes alcohol regularly
______ Patient reports use/abuse of substances other than alcohol
______ Patient has taken time off work due to his/her symptoms
during last six months
______ Patient has suffered an injury on the job
______ There has been a traumatic event in patient life during the
last six months
______ Trauma experienced by patient occurred longer than six
months ago
______ Patient reports increase in anxiety and irritability due to
physical symptoms
______ Patient has good familial and psychosocial support system
______ Patient's symptoms seem to have negative impact on his
familial, interpersonal and social relationships
______ Patient has been treated for similar symptoms in the past
on inpatient and/or outpatient basis
______ Time off work appears to help the patient
______ His/her symptoms appear to be work related
______ The extent of patient's disability is significant but of
temporary nature
______ Patient's condition appears to be significant with permanent
disabling effects
______________________________ ________________
Clinical staff Date
COPYRIGHT (C) 1997 IMH-Network
_______________________________________________________________________________
Patient ID: 3112345 07/26/95
SUBSTANCE ABUSE INDEX
|TCS| |RANGE | FLAGS
--------------+---+-----+----+----------+----------+-----------+------+-------
Current| 41|****************** |Medium|
Past| 32|************** |Medium|
Residual| 31|************* |Medium|
--------------+---+-----+----+----------+----------+-----------+------+-------+
CLINICIAN'S ASSESSMENT OF PATIENT'S SUBSTANCE ABUSE
Type(s) of substances used:_______________________________________________
Extent of use (daily): ___________________________________________________
Duration of use: _________________________________________________________
Emotional impact: ________________________________________________________
Mental impact: ___________________________________________________________
Physical impact: _________________________________________________________
Spiritual impact: ________________________________________________________
Impact on sexual functioning: ____________________________________________
Impact on family: ________________________________________________________
Social impact: ___________________________________________________________
Legal consequences: ______________________________________________________
Economic impact: _________________________________________________________
Occupational impact: _____________________________________________________
Impact upon leisure: _____________________________________________________
Comments: ________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
_______________________________ _________________
Clinical staff Date
COPYRIGHT (C) 1997 IMH-Network
_______________________________________________________________________________
Patient ID: 3112345 07/26/95
GLOBAL ASSESSMENT OF FUNCTIONING
|TCS|
-------------+---+-----+-----+-----+-----+-----+-----+-----+-----+-----+------+
GAF| 55|*********************************
-------------+---+-----+-----+-----+-----+-----+-----+-----+-----+-----+------+
CLINICIAN'S ASSESSMENT OF PATIENT'S CURRENT FUNCTIONING
(choose only one)
(90-100) _____ Superior functioning in all ares
(80-90) _____ Good functioning in all areas
(70-79) _____ Transient symptoms and slight functional impairment
(60-69) _____ Mild symptoms and mild functional impairment
(50-59) _____ Moderate symptoms and moderate functional impairment
(40-49) _____ Severe symptoms and severe functional impairment
(30-39) _____ Moods mostly bad, difficulty communicating
(20-29) _____ Mostly unable to function
(10-19) _____ Primary suicidal and/or aggressive tendencies
(0-9) _____ Not even minimal functioning
___________________________ _____________________
Clinical staff Date
REASSESSMENT OF PATIENT'S FUNCTIONING AFTER ____ DAYS:
_______ ____________________________________________________________
Score Observations
___________________________ _____________________
Clinical staff Date
REASSESSMENT OF PATIENT'S FUNCTIONING AT DISCHARGE:
_______ ____________________________________________________________
Score Observations
___________________________ _____________________
Clinical staff Date
COMMENTS:
________________________________________________________________
________________________________________________________________
________________________________________________________________
COPYRIGHT (C) 1997 IMH-Network
_______________________________________________________________________________
Patient ID: 3112345 07/26/95
ICD-9 / DRG CODE TABLE
ITEMS ICD-9 MDC DRG MVRW INDEX
1. 291 303 20 434-437 0.8267
2. 995.3 21 447 448 0.4221
4. 711 716 08 240 241 244 245 0.7411
13. 296 19 430 0.9040
35. 346 01 024-026 0.8504
47. 302 19 432 0.7113
74. 368.8 02 046-048 0.5151
75. 784.0 01 024-026 0.8504
76. 389.9 03 073 074 0.5501
77. 781.1 01 034 035 0.8516
78. 787.2 06 182-184 0.6214
79. 521.0 03 185-187 0.5893
80. 054.9 09 283 284 0.6004
81. 780.1 19 425 0.7045
82. 783.1 10 296-298 0.6486
83. 724.2 08 243 0.6834
84. 626.6 13 358 359 0.9395
85. 611.72 09 276 0.6085
86. 296.2 19 430 0.9040
87. 558.9 06 182-184 0.6214
88. 782.9 09 283 284 0.6004
89. 786.2 04 099 100 0.6336
109. 784.2 09 283 284 0.6004
110. 783.2 10 296-298 0.6486
111. 788.41 11 325-327 0.5914
112. 698.9 09 283 284 0.6004
113. 611.71 09 276 0.6085
114. 785.6 16 398 399 0.9413
139. 477.9 03 068-070 0.6114
140. 784.1 03 073 074 0.5501
141. 709.0 09 283 284 0.6004
142. 782.0 01 034 035 0.8516
143. 781.1 01 034 035 0.8516
144. 525.1 03 185-187 0.5893
145. 781.0 01 034 035 0.8516
146. 346.8 01 024-026 0.8504
147. 780.9 23 463 464 0.5922
148. 788.6 11 325-327 0.5914
149. 520.0 03 185-187 0.5893
162. 784.9 03 073 074 0.5501
164. 784.9 03 073 074 0.5501
165. 592.0 11 323 324 0.5620
166. 788.7 11 323 324 0.5620
167. 627.2 13 358 359 0.9395
179. 626.4 13 358 359 0.9395
180. 784.2 09 283 284 0.6004
181. 783.0 10 296-298 0.6486
182. 536.8 06 182-184 0.6214
183. 782.5 23 463 464 0.5922
184. 701.8 09 283 284 0.6004
185. 719.49 08 247 0.5682
186. 781.1 01 034 035 0.8516
201. 782.9 09 283 284 0.6004
202. 302.71 19 432 0.7113
203. 695.3 09 283 284 0.6004
COPYRIGHT (C) 1997 IMH-Network
_______________________________________________________________________________
Patient ID: 3112345 07/26/95
ICD-9 / DRG CODE TABLE
ITEMS ICD-9 MDC DRG MVRW INDEX
204. 793 01 034 035 0.8516
205. V68.1 23 467 0.4469
206. 719.09 08 256 0.6505
207. 382.9 03 068-070 0.6114
223. 611.79 09 276 0.6085
224. 800 804 01 002 027-030 280 1.1922
225. 784.5 01 034 035 0.8516
226. 789.0 06 182-184 0.6214
227. 611.4 09 276 0.6085
228. 724.5 08 243 0.6834
229. 737.9 08 243 0.6834
242. 780.9 23 463 464 0.5922
243. 786.8 04 099 100 0.6336
244. 782.0 01 034 035 0.8516
245. 350.2 01 018 019 0.7564
246. 799.2 19 425 0.7045
247. 780.7 23 463 464 0.5922
248. 719.59 08 247 0.5682
249. 578.1 06 174 175 0.7650
267. 454.9 05 130 131 0.7483
268. 781.9 01 296-298 0.6486
269. 959.0 21 444-446 0.5687
270. V52.3 23 467 0.4469
271. 368.42 02 046-048 0.5151
272. 388.30 03 073 074 0.5501
273. 754.0 470 08 072 256 0.6175
276. V15.82 23 467 0.4469
284. 296 19 430 0.9040
294. 304.9 20 434-437 0.8267
COPYRIGHT (C) 1997 IMH-Network