Free Form 02HM002E (AG-2, Part II) - Oklahoma

*02HM002E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES

Uniform Comprehensive Assessment, Part II Screening and Prioritization Assessment information. Assessors, attach a completed Form 02HM001E,
Uniform Comprehensive Assessment, Part I, Intake and Referral. Consumer last name First MI Social Security number

(Ask) Have you had any problems with your memory that seriously interfere with daily activities? Describe:

Yes

No

Functional assessment (ADLs and IADLs).
Check source of information used for functional assessment. Consumer Other, specify Address all questions to the consumer, if possible. Determine the consumer's actual ability to do the activities. Sometimes caregivers assist the consumer with an item regardless of the person's ability. Ask enough questions to be sure you know what the consumer can or cannot do. ADL/IADL total score: Add all scores of two or more and place in the total score box. ADL/IADL impairment count: Count one impairment for each item scored two or more and place in impairment count box. Response definitions: 0 = No assistance: Consumer needs no assistance to perform any part of activity. 2 = Some assistance: Consumer needs assistance of another person, reminders or supervision during part of activity. 3 = Can't do at all: Consumer cannot complete activity without total assistance of another person.

Activities of daily living (ADLS). Read all choices before taking answer.
(Ask) Would you say that you need help: 1. dressing. Includes getting out of clothes, putting them on, fastening them, and putting on shoes. Comments/service plan implications: 2. bathing. Includes running the water, taking the bath or shower, and washing all parts of the body, including hair. Comments/service plan implications: 3. eating. Includes eating, drinking from a cup, and cutting foods. Comments/service plan implications: OKDHS issued 11-10-2006 02HM002E (AG-2, Part II) 0 2 3

0 0

2 2

3 3

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02HM002E (AG-2)

Uniform Comprehensive Assessment

4. transferring. Includes getting in and out of a tub, bed, chair, sofa, vehicle, and others. Comments and service plan implications: 5. bladder/bowel control. How often do you have bladder or bowel accidents? Never (0) Occasionally (2) Often (3) Always (4) Comments and service plan implications: 6. toileting. How well can you manage the toilet? Independence includes adjusting clothing, getting to and on/off the toilet, and keeping yourself clean and dry. If no accidents occur and person manages it alone, count as No assistance. If reminders are needed, count as Some assistance/supervision. ADL total score ADL impairment count 0

0

2

3

2

3

4

0

2

3

Instrumental activities of daily living (IADLS). Read all choices before
taking answer. (Ask) Would you say that you need help with: 7. transportation. Arranging and using local transportation, or driving to places beyond walking distance, to get to places you need to go. Comments/service plan implications: 8. meal preparation. Making sandwiches, cold or cooked meals, TV dinners, and the like, so that you won't go hungry. Does not refer to quality of nutritional content. Comments/service plan implications: 9. light housekeeping. Includes dusting, vacuuming, sweeping, and the like. Does not include laundry. Comments and service plan implications: IADL total score IADL impairment count Check source of information used for consumer support and social resources. Consumer Other, specify 0 2 3

0

2

3

0

2

3

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OKDHS issued 11-10-2006

Uniform Comprehensive Assessment

02HM002E (AG-2)

Consumer support:
Complete for services and assistance received and needed. (Ask) Do you receive assistance with: 1. personal care, such as bathing, dressing, getting out of bed, toileting, and eating. Notes: 2. housekeeping, such as laundry, cleaning, or meals. Notes: 3. transportation. Notes: 4. taking or managing medication. Notes: 5. shopping or errands. Notes: 6. personal finances, that is, money management. Notes: 7. services of a health professional, such as RN or therapist. Notes: 8. adult day care. Notes: 9. home delivered meals, formal services only. Notes: 10. any other kind of assistance, specify Notes: Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No

Scoring matrix
Instructions: For items 1, 2, 3 and 5 in the scoring matrix below, enter the value in parentheses that corresponds to the response obtained during the interview. Example: if the answer was yes to the question "Does the consumer live alone?" then a score of one point is placed on the line next to the answer line marked yes. For item 4, Functional Assessment, enter the score of ADLs and IADLs from the screening form. Impairment count: Enter the impairment count from the Functional assessment section ADLs and IADLs impairment count box in Form 02HM003E, Uniform Comprehensive Assessment, Part III, in the space provided in item 4 under the Domain/Question column on the left. Do not add counts into scores. Total score/risk category: Add the numbers for each item in the Score column on the right to determine the total score and place the score in the box marked total score. Check the risk category that encompasses the total score in its scoring range.

OKDHS issued 11-10-2006

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02HM002E (AG-2) Domain/question

Uniform Comprehensive Assessment Score

1. Does consumer live alone? Yes (0) No (2) See Form 02HM001E, Uniform Comprehensive Assessment, Part I. 2. Is the assistance of another person required for the consumer to leave home (homebound)? See Form 02HM001E. Yes (0) No (2)

3. Does consumer have memory problems? Yes (0) No (2) See Form 02HM003E, Uniform Comprehensive Assessment, Part III 4. Functional assessment, see Form 02HM003E, pages 1 - 2 ) Enter score ADLs (Enter count: IADLs (Enter count: ) Enter score 5. Consumer support, see page 3 of this form. Does consumer currently receive assistance or services, formal or informal, in ADL or IADL deficit areas noted? No assistance available (3 pt.) Assistance is available, but overall inadequate, changing, fragile, or problematic (2 pt.) Assistance is adequate overall in deficient areas (0 pt.) Total score Risk category, check one: Low (0 - 5) Moderate (6 - 26) High (16 - 35) Screener override of risk category: Screener supervisor ONLY Approve override? Yes No Yes Supervisor's signature Date

Written justification, attach extra pages if needed:

Screener's signature

Date

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OKDHS issued 11-10-2006