Effective Date: 
11/2016

Documents

Instructions

Updated: 8/2016

Purpose

To provide a guide for completion of the comprehensive nursing assessment for individuals in the Community Living Assistance and Support Services (CLASS) and Deaf Blind with Multiple Disabilities (DBMD) waiver programs. Form 6515 is intended to provide a complete picture of the individual's needs from a nursing perspective, to provide integral information for the justification of program services, to improve the coordination of care for individuals, and to promote the health and safety of individuals in the CLASS and DBMD program.

Procedure

See the nursing procedures for timing of completion and detailed information specific to each program for the nursing staff.

Prior to completion of Form 6515, review the entire document for the information it provides. While completing the assessment, keep in mind that the individual program plan (IPP), individual plan of care (IPC), and the Personal Assistance Services/Habilitation (PAS/HAB) Plan are often justified by the needs identified on Form 6515.

If the information is unavailable for a particular question, the nurse should document that the information is unavailable in the space provided or in the corresponding comments section. For example, “unable to obtain” or “poor historian.”

If the individual refuses examination of a particular area and the registered nurse (RN) is unable to assess, that information can be provided in the comments section.

For items that cannot be assessed, it is acceptable to document that the information was obtained through the individual/legally authorized representative (LAR) or the historian noted on Page 1. If someone other than the individual/LAR or the historian noted on Page 1 provides the information, document that on the form as close to the response as possible.

When to Prepare

Enrollment in the CLASS/DBMD Program

For CLASS, Form 6515 should be completed and submitted to the Texas Health and Human Services Commission (HHSC) in conjunction with the Adaptive Behavior Level (ABL) Assessment and Form 8578, Intellectual Disability/Related Condition Assessment.

For DBMD, Form 6515 can be completed separate from the ABL Assessment and Form 8578, but all three documents are submitted with the Enrollment Packet.

Reassessment

For CLASS, Form 6515 must be completed in conjunction with the ABL Assessment and Form 8578 on an annual basis.

For DBMD, Form 6515 can be completed separate from the ABL Assessment and Form 8578; however, all three documents must be included with the Renewal Packet.

Post-Hospitalization

For CLASS, Form 6515 must be completed within 48 hours of discharge unless a physician specifies in writing that no changes to the IPC are required. An RN may use this form for the post hospital assessment or can use a form of his/her choosing that is consistent with Home and Community Support Services Agency (HCSSA) licensure requirements.

Number of Copies

One original and one copy.

Form Retention

Retain a copy in the individual's chart for the length of time instructed by HHSC.

Transmittal

The original Form 6515 is sent to HHSC state office.

Utilization Management and Review
CLASS/DBMD, Mail Code: W-521
P.O. Box 149030
Austin, TX 78714-9030

Detailed Instructions

Individual’s Name, Medicaid Number, and Assessment Date — Enter the individual’s name as it appears on the IPC. The RN will enter the date time the assessment was conducted. On all subsequent pages, the individual’s name, Medicaid number, and the assessment date will automatically appear.

Date of Birth and Male or Female — Enter the individual's date of birth and check the box for male or female.

History received from and relationship — Document the primary informant for this assessment and his/her relationship to the individual.

Reason for Assessment — Mark the appropriate box: Initial Assessment, Annual Reassessment, Post Hospitalization, Protective Devices (DBMD only), Change in  Needs, Change in Service Delivery Option, or Other (specify in the space provided).

Living Arrangement — Mark the appropriate box to indicate if the individual lives in their own home/family home, a 1-3 bed home, or a 4-6 bed assisted living facility.

Number in household — Enter the number of people living in the individual's household.

Primary support provider — Enter the primary support provider for the individual. This could be paid staff or a natural support person. If not applicable, mark N/A in the space provided.

Home conditions — Mark to indicate if the home is clean or unclean.

Safety — Mark to indicate if the safety of the individual's living arrangement is good, fair or poor.

Hygiene — Mark to indicate if the hygiene of the individual's living arrangement is good, fair or poor.

Comments — Provide any other related comments to the individual's living arrangements. Program staff cannot dictate specific levels of home repair, maintenance or cleanliness, unless it potentially qualifies as abuse or neglect. Information regarding the reporting of those issues is included. Examples: Case Management can offer to assist an individual in finding safer housing. Home modifications can be planned to meet access needs. Additional attendant care can be provided to assist with cleanliness in areas that the participant uses. Attendant care can be supplied to meet health and safety supervision needs.

Communication — Mark Yes or No for each selection that applies to the individual to indicate how the individual communicates: Verbal, Limited verbal, Non-verbal, Gestures, Communication symbols, Facial expressions, Eye movements, Paralinguistic (sounds), Touch, Body language, Acting out, Head banging, Other behaviors and Numeric scale. Note: Communication needs must be facilitated and addressed if assistance is needed.

Comments — Provide any explanations of modes of communication marked “yes” and any other comments related to the individual’s communication.

Immunizations — Mark the appropriate box to indicate if the individual is up to date on all immunizations: Unknown, Yes, No, Childhood, Adult Recommended Vaccines, Influenza and Pneumococcal. Mark all that apply. Program staff can work with the family to assure that the individual receives appropriate medical care. For this program and this document, program staff collect the information regarding an individual’s immunization status but make no judgment on the decision to vaccinate or not vaccinate.

Adverse Reactions — List any adverse reactions the individual has had to immunizations.

Comments — Provide any other comments related to individual's immunizations.

Known Allergies/Reaction/Prevention/Action Needed (food and environmental, record medication allergies on medication sheet) — Document any known allergies the individual has including food and environmental. If none are known, indicate “none.” Medication allergy information should be documented on the medication sheet.

Note: Allergies, reactions, methods for prevention and needed action when exposed to a food or environmental allergen should be known to the attendant care staff to avoid exposure to potential allergens and respond appropriately when exposure occurs.

Current Medical and Mental Health Diagnoses and Dates Diagnosed — Document the individual's medical and mental health diagnoses (as identified by a professional with the authority to diagnose) with the date of the diagnosis.

Previous Medical, Surgical and Mental Health History and Dates — Document the individual's medical, surgical and mental health history including information such as medical treatments, surgeries, hospitalizations, mental health treatments and the dates of each occurrence. Note: Medical and surgical history identify potential problems in the provision of care, i.e., Herrington Rod surgery means that the back cannot be bent where the rods were placed. The attendant care staff should be made aware of the limitation of movement.

Precautions and Contraindications — Indicate any precautions or contraindications associated with the individual’s identified medical or mental health diagnoses, and medical, surgical and mental health history.

Airborne Communicable Disease — Document if the individual has been tested for tuberculosis (TB) in the past year. If yes, indicate the type of test used (blood draw, purified protein derivative (PPD) skin test or chest x-ray) and provide the date of the test, as well as the results.

Does the individual have any active reportable communicable diseases? — Mark Yes or No. If yes, specify the type of communicable disease.

Vital Signs — Provide the individual’s vital signs: Blood Pressure (B/P), Pulse, Height in feet and inches, Respirations, Temperature, Weight in pounds (lbs), and Blood Sugar (indicate if it was self-reported, last machine reading/log book, or nurse verified with finger stick).

Note: If the nurse does not feel that blood sugar is a necessary vital sign for the individual, the nurse may mark N/A in the space provided.

Pain — Mark Yes or No to indicate if the individual is in pain. If yes, provide the current intensity of the pain on a scale from 0-10 and document the acceptable level of pain for that individual on a scale of 0-10.

Location of the pain — Describe the location of the pain.

What relieves the pain? — Describe what relieves the individual's pain.

How do you know the individual is in pain? — Describe how you know the individual is in pain.

Neurological/Musculoskeletal— Mark all that apply to indicate if the individual is:

Alert and oriented to — Mark Person, Place, Time or None if the individual is not alert and oriented to person, place or time.

Note: Special needs for supervision or assistance are identified in this section and should be communicated to attendant care staff.

Memory Deficits — Mark Yes or No. If yes, indicate the type of deficits: Slow to respond, Forgetfulness, Short-term memory loss, Long-term memory loss.

Note: Response can be based on a diagnosis, observation and/or reported information from the individual or historian.

Pupil Reaction — Mark if the individual has pupil reaction in the right eye and left eye. Mark if the individual’s eye is open: right eye, left eye.

Motor Movement — Mark to indicate if the individual has motor movement in the right upper extremity (RUE), left upper extremity (LUE), right lower extremity (RLE) or left lower extremity (LLE).

Contractures — Mark Yes or No. If yes, enter the location.

Paralysis — Mark Yes or No. If yes, enter the location.

Syncope — Mark Yes or No.

Decreased Grasp — Mark to indicate if the individual has decreased grasp in right or left hand.

Decreased Movement — Mark to indicate if the individual has decreased movement in the RUE, LUE, RLE or LLE.

Weakness — Mark Yes or No to indicate if the individual has weakness. If yes, indicate the location.

Seizures — Mark Yes or No. If yes, describe the type, duration, last seizure, and frequency.

Sensation — Mark Intact or Diminished/Absent, if Diminished/Absent explain.

Sleep Aids — Mark Yes or No. If yes, list sleep aides other than prescription medicine. Note: Prescription sleep aids should be noted under "medications."

Gait — Mark Steady or Unsteady to indicate the individual’s gait.

Comments — Provide any comments related to the individual's neurological/musculoskeletal status.

Eyes, Ears, Nose and Throat

Eyes/Vision — Mark to indicate the individual’s eyes/vision are: Clear, Red, Right impaired vision, Left impaired vision, or Adaptive aid. If an individual requires an adaptive aid for his/her eyes or vision, mark Adaptive aid and document what type in the space provided.

Ears — Mark to indicate the individual’s ears and hearing are: Normal, Ringing, Right impaired hearing, Left impaired hearing or Adaptive aid. If an individual requires an adaptive aid for his ears or hearing, mark Adaptive aid and document what type in the space provided.

Nose/Smell — Mark to indicate the status of the individual's nose/smell is: Within normal limits (WNL), Intact, Not intact or Nose bleeds. If nose bleeds, mark how many per week. If applicable, mark Frequent sinus congestion or Frequent sinus infections.

Oral — Mark to indicate the individual’s oral status is: WNL, Difficulty chewing, Mouth pain, Halitosis, Dentures, Toothless/Missing teeth or Involuntary tongue movement.

Throat — Mark to indicate the individual’s throat is: WNL, Throat pain, Difficulty swallowing or History of choking.

Comments — Provide any comments related to the individual's eyes, ears, nose and throat.

Respiratory — Mark to indicate the individual's respirations are: Regular, Unlabored, Irregular or Labored. Note: Respiratory function is a life or death issue. The nurse should also identify needs as they apply to service delivery and follow up with nursing needs/delegation activities, as needed.

Right Breath Sounds — Mark Clear, Rales, Rhonchi, Wheezing or Stridor.

Left Breath Sounds — Mark Clear, Rales, Rhonchi, Wheezing or Stridor.

Shortness of breath — Mark Yes or No. If yes, indicate triggers.

Respiratory treatments — Mark None, Oxygen, Aerosol/Nebulizer, Continuous Positive Airway Pressure/Biphasic Positive Airway Pressure (CPAP/BIPAP), Suctioning or Trach. If yes, indicate trach size and type.

Comments — Provide any comments related to the individual's respiratory system.

Cardiovascular — Mark to indicate the individual’s cardiovascular health history is: N/A, Arrhythmia, Hypertension, Hypotension or Dizziness.

Pulse — Mark Regular or Irregular.

Edema — Mark Yes or No.

Pitting — Mark Yes or No. If yes, indicate 1+ for mild, 2+ for moderate, 3+ for deep or 4+ for very deep.

Location of Edema — Enter the location of the individual's edema.

Comments — Provide any comments related to the individual's cardiovascular health.

Gastrointestinal — Mark to indicate if the individual’s diet requirement is: Regular, No added salt, Diabetic/No concentrated sweets, Mechanical soft, Pureed, High calorie or Other and indicate what type in the space provided. Mark if the individual takes any supplements and indicate the type in the space provided.

Note: Identify any special needs such as tube feeding or choking problems and follow up with nursing needs/delegation activities, as needed.

Number of meals/day and Number of snacks/day — Enter the number of meals and number of snacks the individual consumes each day.

Is there evidence of or a risk for malnutrition or dehydration? — Mark Yes or No. If yes, explain.

Is any nutritional/fluid monitoring necessary? — Mark Yes or No. If yes, describe type/frequency.

Are assistive devices needed? — Mark Yes or No. If yes, explain.

Does the individual have a feeding tube? — Mark Yes or No. If yes, indicate the type of device used: Gastrostomy (G-tube), Mic-key button, Percutaneous endoscopic gastrostomy (PEG tube) or Gastrojejunostomy (GJ tube).

If yes, indicate the type of feeding tube.

Provide the type of formula, amount and frequency, and if administered by pump or bolus.

Is there any leakage noted? — Mark Yes or No. If yes, is there a skin barrier in place? Mark Yes or No.

Mucous membranes — Mark Moist or Dry.

Nausea — Mark Yes or No and provide the onset.

Vomiting — Mark Yes or No and provide the onset.

Bowel sounds — Mark Normoactive, Hyperactive, Hypoactive, Right Upper Quadrant (RUQ), Right Lower Quadrant (RLQ), Left Upper Quadrant (RUQ) or Left Lower Quadrant (LLQ).

Last bowel movement — Provide the day and time of the last bowel movement.

Ostomies — Mark Yes or No. If yes, provide where.

Mark all that apply — Mark Incontinent, Flatus, Belching, Laxatives, Enemas, Suppositories, Constipation, Diarrhea (provide frequency), and Bowel Management Program. If yes provide the regimen.

Comments — Provide any additional information related to the individual's gastrointestinal health.

Genitourinary — Mark all that apply: Normal, Dribbling, Incontinent, Frequency, Burning, Nocturia, Hematuria, Stones, Stoma, Difficulty starting stream, Retention, Distension, Catheter (if marked provide the type, size and last changed), Dialysis (if marked indicate shunt bruit +/-, thrill +/-, and the frequency of dialysis.

Note: The nurse should identify special needs that will affect the individual’s care.

Comments — Provide any additional information related to the individual's genitourinary health.

Skin — Along with completion of this section, Form 6515, Addendum A, Braden Scale For Predicting Pressure Sore Risk in Home Care, must be completed for all individuals.

Note: The nurse should identify any special needs and follow up with nursing needs/delegation activities, as needed.

Intact — Mark Yes or No. If no, a detailed assessment of the skin must be completed using Form 6515, Addendum B, Bates-Jensen Wound Assessment. Mark all that apply: Normal, Red, Rash, Irritation, Abrasion, Pink, Cyanotic, Pale, Mottled, Warm, Cool, Dry, Diaphoretic and Other. If Other is marked, explain in the Comments section.

Any skin conditions requiring treatment or monitoring?Mark Yes or No. If yes, describe the condition and treatment.

Skin tufor Mark good, fair or poor.

CommentsProvide any additional information related to the individual's skin.

Functional AbilitiesMark Independent, Needs Assistance or Dependent for each activity listed. Responses should be consistent with those contained in the IPC, IPP and/or PAS/HAB Plan (Hygiene, Toileting, Dressing, Shopping, Meal Preparation, Eating, Exercise, Transfer/Ambulation, Cleaning, Community Assistance, Supervision). If applicable, provide Recommendations and Comments.

IndependentMark this option if the individual does not require any hands-on assistance to complete the activity. If the individual can do the task but requires prompting or reminders, indicate that in Comments.

Needs AssistanceMark this option if the individual can complete some parts of the task but cannot complete the entire task without assistance. If the individual needs assistance but can self-direct the task, indicate that in Comments.

DependentMark this option if the individual cannot complete any part of the task independently. If the individual is dependent on others to do the task but can self-direct, indicate that in Comments.

RecommendationsProvide any recommendations.

CommentsProvide any additional comments.

PsychosocialMark N for Never, O for Occasional, R for Regular or C for Continuous for each condition /behavior listed: Receptive/Expressive Aphasia, Wanders, Depressed, Anxious, Agitated, Disturbed Sleep (including unusual sleeping patterns i.e. naps, frequent waking, etc.), Resists Care, Disruptive Behavior, Impaired Judgment, Unsafe Behaviors, PICA, Hallucinations, Delusions, Aggression, Dangerous to Self or Others, Does the individual smoke?, Does anyone in the environment smoke?, Does the individual drink alcohol?, Does the individual use recreational drugs? If response is anything other than never, explain.

Note: Program staff cannot dictate an individual’s preferences or lifestyle, but knowledge of individual lifestyles and preferences can assist the team in planning attendant care and to respond to crises.

SafetyThe IPC, IPP and/or PAS/HAB Plan should incorporate these needs. The nurse and service planning team should pay close attention and have a plan to meet the needs.

Is there an accessible emergency exitMark Yes or No.

Can the individual access the emergency exit?Mark Yes or No. If no, explain.

Is there a safety plan in the case of an emergency?Mark Yes or No. If no, explain. A safety plan is a personalized, practical plan that can be used by anyone to avoid dangerous situations (fire, home invasion, tornado, etc.) and know the best way to react if in danger. A safety plan should be developed to ensure the individual can safely and quickly evacuate the residence. The plan should include ensuring the individual can safely navigate to the most accessible exit point of the residence. For additional information or to assist the individual in making a plan, please visit www.ready.gov/make-a-plan.

Protective Devices (PD) (DBMD only)

Does the individual use a PD?Mark Yes or No. If yes, complete Form 6515, Addendum C, Protective Devices.

Restraint Risks (DBMD only)

Is there a physician’s order for a restraint?Mark Yes or No.

To your knowledge, are there any risks associated for this individual with the use of the restraints listed below? — Mark Yes or No, based on RN awareness of risks. Mark physical, mechanical or chemical if there are risks associated with using that type of restraint with the individual. If checked provide details in the associated risk section below.

Provide Age, Height, Weight, Emotional Condition (including history of abuse, neglect exploitation or trauma), Ability to communicate, Physical/Medical Conditions, or Other and explain. The RN may review medical and social histories or any other available documents where the individual has disclosed a personal history. When discussing an individual’s emotional condition, be certain to phrase questions in a manner that is sensitive to problems the individual may be experiencing due to any abuse, neglect or exploitation (ANE) the individual may have experienced. If the RN has cause to believe that an individual’s physical or mental health or welfare has been or may be adversely affected by abuse, neglect, or exploitation they must report the case immediately to the Texas Department of Family and Protective Services Abuse/Neglect Hotline at 800-252-5400.

Associated Risks Describe how the risk is contraindicated for the use of restraints. Some examples of risk to individual might be obesity, asthma, heart condition, epilepsy, congenital abnormalities with vertebra in neck due to Down syndrome, history of abuse and/or other trauma, brittle bone syndrome, Harrington Rod, adverse reactions to medications, skin breakdown if mechanical restraints are indicated in behavior support plan, etc. This list is not exhaustive. These are only some examples.

Does the individual have a behavior support plan at this time?Mark Yes or No. If no, and the RN recommends consultation with a doctor or psychologist for a behavior assessment indicate that in the risks, recommendations and/or considerations space provided.

Limitations Based on Risks Describe the limitations to restraint use because of the risks indicated.

What are the risks, recommendations and or considerationsProvide any risks, recommendations and/or considerations as well as any additional information related to restraint risks.

CommentsProvide any additional information related to restraint risks.

Health-Related Tasks

ActivitiesMark Independent, Needs Assistance or Dependent for each activity listed. Responses should be consistent with those contained in the earlier sections of this form, the IPC, IPP and/or PAS/HAB Plan (bowel program, wound care, suctioning, administration of medications, catheterization, tube feeding, trach care, extension of therapy, other). If applicable, provide Comments and Recommendations.

Independent Mark this option if the individual does not require any hands-on assistance to complete the activity. If the individual can do the task but requires prompting or reminders, indicate that in Comments.

Needs AssistanceMark this option if the individual can complete some parts of the task but cannot complete the entire task without assistance. If the individual needs assistance but can self-direct the task, indicate that in Comments.

DependentMark this option if the individual cannot complete any part of the task independently. If the individual is dependent on others to do the task but can self-direct, indicate that in Comments.

** The RN must refer to Addendum D: Delegation of Tasks if there are any activities that are marked as “Needs Assistance” or “Dependent” or if the individual or Legally Authorized Representative (LAR) is unable to self-direct care and the RN determines the task must be delegated. If the RN determines the task to be a HMA Addendum D is not needed.

Indicate Code Enter appropriate code (F, P, N, D, C, T or HMA) to indicate if the health-related task is to be:

  • F — provided by family, friend or other non-waiver resource;
  • P — physician delegated;
  • N — nurse;
  • D — RN delegated; or
  • C — Consumer Directed Services
  • T — Therapist Delegated (only for extension of therapy)
  • HMA — RN determined this task to be a Health Maintenance Activity

RN Delegation and Tasks Not Requiring RN Delegation in Independent Living Environments with Stable and Predictable Individual Condition: Professional Nursing Assessment GridUse the assessment criteria and the assessment findings to determine and record a score for each section. Provide the sum of the five sections in the box marked total score. Provide the frequency of reassessment score in the space provided.

Level of Participation/Responsibility in Health Care Management (Must complete Option A, B or C)Indicate the individual's level of participation and accepted responsibility in his/her health care management by marking in the most appropriate Option. Print the individual's name, obtain the individual's signature and enter the date the form is signed.

  • Option AThe RN must indicate the tasks that they have determined can be directed by the individual or the individual’s responsible adult to be performed by an unlicensed person without RN supervision. The RN signs to confirm marking this option indicates the individual/LAR agrees to participate in directing the unlicensed person’s actions in carrying out the indicated tasks as a health maintenance activity and the individual/LAR is willing and able to train the unlicensed person in the proper performance of the task(s). If the LAR is participating as the individual’s responsible adult, the LAR will be present when the task is performed or, if not present, has observed the unlicensed person perform the task(s) at least once to assure the unlicensed person can competently perform the task(s) and the LAR will be immediately accessible in person or by telecommunications when the task(s) is performed. The individual or individual’s LAR signs to confirm.
  • Option BTo be completed by the individual or LAR attesting. Marking this option indicates the individual/LAR has participated in but does not accept responsibility for decisions about the overall management of the individual’s health care. [Title 22 of Texas Administrative Code (TAC) §225.1(a)(2)] The individual or LAR must then provide a designee name and relationship. The designee signs to confirm and the individual or LAR signs to confirm.
    Note: If Option B is selected, ensure completion of Form 6515, Addendum D, Delegation of Tasks.
  • Option CThe individual uses the Consumer Directed Services option and elects to take responsibility for some nursing tasks as allowed under Title 4 of the Texas Government Code §531.051(e).
  • Option DMarking this section indicates that the RN has identified tasks as unable to be performed by an unlicensed individual. The individual or LAR must then select one of the options provided.

Medications and TreatmentsNote: You may attach signed prescriber's orders or a verified prewritten list as an alternative to completing this page.

AllergiesList all medication allergies the individual has.

Medication/Treatment Name, Dose, Route, Frequency, IndicationList all medications and treatments, including as the circumstance arises (PRN), over-the-counter (OTC), herbal and dietary supplements. If additional space is needed, copy this page and attach.

Related monitoring and testing (if any)Provide any monitoring or testing needed for the medications indicated on this page.

Attached verified medication listMark if using an attached verified medication list instead of this form.

Have there been any recent changes in the medications?Mark Yes or No. If yes, explain.

CommentsProvide additional information related to the individual's medications and treatments.

RN blank at the bottom of all pages of Form 6515The registered nurse (RN) completing the form signs and dates the bottom of each page.

ADDENDUM INSTRUCTIONS

Form 6515, Addendum A, Braden Scale For Predicting Pressure Sore Risk in Home Care

RN Completing AddendumRN signs his/her name at the bottom of each page of this addendum.

Note: This addendum must be completed as part of all comprehensive nursing assessments to determine if the individual has a risk for pressure sores.

Individual's Name and Assessment DateEnter the individual's name, and assessment date and time at the top of the page.

Enter a score of 1, 2, 3 or 4 for each category (Sensory Perception, Moisture, Activity, Mobility, Nutrition), Enter a score of 1, 2, or 3 for Friction and Shear. Total the score and provide any recommendations based on the findings.

Form 6515, Addendum B, Bates-Jensen Wound Assessment

RN Completing AddendumRN signs his/her name at the bottom of each page of this addendum.

Note: This addendum must be completed if any part of the skin is identified as not intact in the skin assessment. One addendum may be used for multiple wounds. If the individual refuses examination or the wound is covered and being cared for by family or another healthcare provider, document this in the recommendations/comments section at the end.

Individual's Name and Assessment DateEnter the individual's name and assessment date at the top of the page.

Location: Anatomic siteCircle and identify right (R) or left (L) and use X to mark the site on the body diagrams: Sacrum and Coccyx, Trochanter, Ischial tuberosity, Other, Lateral ankle, Medial ankle, Heel and Tube site.

Shape: Overall wound pattern Assess and circle and date the appropriate description: Irregular, Round/oval, Square/rectangle, Linear or elongated, Bowl/boat or Butterfly.

Complete the rating to assess wound status. Evaluate each item by selecting the response that best describes the wound. Enter the date in the Date column and the score in the Score column: Size, Depth, Edges, Undermining, Necrotic tissue type, Necrotic tissue amount, Exudate type, Exudate amount, Skin color surrounding wound, Peripheral tissue edema, Peripheral tissue induration, Granulation tissue and Epithelialization.

Total ScoreEnter the total score.

RecommendationsProvide any recommendations as a result of the findings.

Wound Status ContinuumIndicate the score on the wound status continuum, as directed on the form.

Form 6515, Addendum C, Protective Devices (DBMD Only)

RN Completing AddendumRN signs his/her name at the bottom of each page of this addendum.

Individual's Name and Assessment DateEnter the individual's name and assessment date at the top of the page.

What is the medical condition that necessitates a protective device (PD)?Enter the condition.

What type of PD is being used?Enter the device type.

Under which circumstances (where and when) will the PD be used for the individual?Explain.

How is the PD to be used?Explain.

Are there any contraindications to the use of the PD for this individual?Mark Yes or No. If yes, explain.

How and when should the use of a PD be documented for this individual?Explain.

How should the use of the PD be monitored . . . ?Explain

When and whom must the program staff notify of the use of the PD?Mark all that apply including RN, Physician, Other and specify, First time PD is used, Change in status, Weekly, Monthly, Quarterly, Biannually, Annually, Other and specify.

Annual/Periodic Evaluation of Effects of PD on Health and Welfare

Is there a current need for continued use of the PD?Mark Yes or No. If yes, explain.

Is the device contributing to the overall health and well-being of the individual?Mark Yes or No. If no, explain.

RN Completing Addendum CRN signs his/her name at the bottom of each page of this addendum.

Protective Device Usage LogThis log (optional tool) may be completed to assist the provider in documenting protective devices as required by 40 TAC §42.408. Providers are not required to use this tool but are required to meet the documentation requirements outlined in 40 TAC §42.408.

Service providers use the log to document the use of the PD based on the RN’s recommendations. The appropriate professional, as identified by the RN, should monitor the log according to the schedule identified by the RN.

DateEnter the date the PD is used.

Device UsedEnter the type of PD used.

Need IndicatedEnter the need for the PD.

Status of Device UseMark all boxes that apply to indicate: In place upon arrival, Initiated at (time) and provide the time, Discontinued at (time) and provide the time, Improperly placed (if marked, explain), Not in proper working order (broken, missing parts, etc.), Continued past shift.

Location of DeviceEnter the location of the PD on the body.

Employee SignatureSelf-explanatory.

Form 6515, Addendum D, Delegation of Tasks

RN Completing AddendumRN signs his/her name at the bottom of this addendum.

Individual’s Name and Assessment DateEnter the individual’s name and assessment date at the top of the page.

Employee Name and SignatureProvide the name and signature of the employee whose competence is verified or who the task is delegated to.

TaskEnter the task to be delegated.

Competency Verified or DelegationMark Competency Verified and/or Delegated.

DateEnter the date verified competent and/or delegated.

Form 6515, Addendum E, Recommendations/Coordination of Care

This addendum is designed to provide a format to ensure coordination of care between issues identified by the RN to the service planning team (SPT) so that appropriate services are considered for the individual’s unique needs.

The RN who completes the assessment completes this addendum, filling in information, as appropriate, based on his/her judgment as an RN. The RN lists the primary areas of  concern based on the assessment; identifying systems and the concern/recommendations; summary of nurse’s findings and recommendations; restraint risks (DBMD Only); and the need to discharge. The RN signs the form and then provides it to the program director who must share the information with the case manager. Both the program director and case manager sign and date to confirm they have reviewed the information.

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