Free Significant Change in Health Screening Instrument Model Form-F-62370 - Wisconsin

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62370 (Rev. 04/09)

STATE OF WISCONSIN

SIGNIFICANT CHANGE IN HEALTH SCREENING INSTRUMENT MODEL FORM
This form may be used when documenting a resident's significant change in condition under DHS 83.42(1)(j). DEFINITIONS Significant Change (a) Decline in a resident's medical condition that resulted in further impairment of a long-term nature. (b) Decline in two (2) or more activities of daily living. (c) A pronounced decline in communication or cognitive abilities. (d) Decline in behavior or mood to the point where relationships have become problematic. (e) Significant improvement in any of the conditions in items (a) to (d). Decline In this context, "decline" is defined as a negative change since the resident was last reviewed.
Name - Resident Name - Facility

Does this resident currently require nursing procedures that can only be performed by an RN or LPN? NO YES If "YES," how many hours per week? _

_
nature?

1.

Has there been deterioration in the resident's medical condition that results in further impairment of a long-term NO YES If "YES," explain deterioration.

2.

Is there deterioration in two or more activities of daily living? NO YES If "YES," list.

3.

Is there a pronounced deterioration in communication or cognitive abilities? NO YES If "YES," explain.

4.

Is there a deterioration in behavior or mood to the point where relationships have become problematic? NO YES If "YES," explain.

If the answer to any of the above is "YES," the resident should be seen by a physician or other appropriate medical professional. [DHS 83.38(1)(g), Wis. Admin. Code] Attach or explain results of medical assessment. Residents who require MORE THAN 3 HOURS PER WEEK of nursing care for MORE THAN 90 DAYS, exclusive of personal care, may not remain in a CBRF unless the department grants a waiver or variance. [DHS 83.27(1)(b), Wis. Admin. Code]

SIGNATURE

Date Signed