loading…
loading…
loading…
State of Maryland Medical Assistance Manual Revised April 2014
Part G – Certification 1. Signature of Person Completing Form:
Date:
Printed Name:
I certify to the best of my knowledge the information on this form is correct.
2. Signature of Health Care Professional:
Date:
Printed Name:
Client Name_____________________________________
Communication (Please answer Yes or No for EACH item.) Answer
Y N 12. Hearing impaired even with use of hearing aid: Difficulty hearing when not in quiet setting, understands conversations only when face to face (lip-reading), can hear only very loud voice or totally deaf.
13. Vision impaired even with correction: Difficulty with focus at close rand, field of vision is severely limited (tunnel vision or central vision loss), only sees light, motion, colors or shapes, or is totally blind.
14. Self Expression: Unable to express information and make self understood using any means (with the exception of language barrier.
Review Item
FUCTIONAL STATUS: Score as Follows 0= independent: No assistance or oversight required 1= Verbal cueing, oversight, encouragement 2= Limited assistance: Requires hands on physical assistance 3= Extensive assistance: requires full performance (physical assistance and verbal cueing) by another for more than half of the activity 4= Total care: Full activity done by another
Score Each Item (0-4) 15. Mobility: Purposeful mobility with or without assistive devices.
16. Transferring: The act of getting in and out of bed, chair or wheelchair. Also, transferring to and from toileting, tub and/or shower.
17. Bathing (or showing): Running the water, washing and drying all parts of the body, including hair and face.
18. Dressing: The act of laying out clothes, putting on and removing clothing, fastening of clothing and footwear, includes prostheses, orthotics, belts or pullovers.
19. Eating: The process of putting foods and fluids into the digestive systems (including tube feedings).
20. Toileting: Ability to care for body functions involving bowel and bladder activity, adjusting clothes, wiping, flushing of waste, use of bedpan or urinal, and management for any special devices (ostomy or catheter). This does not include transferring (see transferring item 16 above.
CONTINENCE STATUS: Score as Follows 0= Independent: Totally continent, can request assistance in advance of need, accidents only once or twice a week or is able to completely care for ostomy. 1= Dependent: Totally incontinent, accidents three or more times a week, unable to request assistance in advance of need, continence maintained on toileting schedule, indwelling, suprapubic or Texas catheter in use or unable to care for own ostomy.
Score Each Item (0-1) 21. Bladder Continence: Ability to voluntarily control the release of urine from the bladder.
22. Bowel Continence: Ability to voluntarily control the discharge of stool from the bowel.
DHMH Form 3871B Rev 10/11 (4 of 4)