SELECT Patient_ID, Last_Name_M0040 AS Last_Name, First_Name_M0040 AS First_Name, Middle_Initial_M0040 AS Middle ,Payer_ID FROM #Request.prefix_db_agency#.patient WHERE Patient_Id = '#session.cs.patientid#' AND Agency_Id = '#session.AgencyId#' select Assessment_ID, Pain1, Pain2, Pain3, pain4, Pain5, Start_of_Care_M0030, Rehab_Prognosis_M0270, Inpatient_Facility_M0855, M0250_Assess, Therapies_Home_M0250, Endocrine_Assess, M0440_Assess, M0420_Assess, Emergent_Care_M0830, Emergent_Care_Reason_M0840, Nursing_Home_M0900, Discharge_Disposition_M0870, Inpatient_Facility_M0855, M0490_Assess, M0520_Assess, M0540_Assess, M0550_Assess, M0610_Assess, Meal_Prep_M0720, Home_Safety_Assess, M0810_Assess, Urinary_INcont_when_M0530, Urinary_INcont_M0520, Bowel_Incont_M0540, Ostomy_for_Bowel_M0550, Cog_Function_M0560, When_Confused_M0570, When_Anxious_M0580, Depressive_Feelings_M0590, Patient_Behav_Weekly_M0610, Patient_Behav_freq_M0620, Psy_Nursing_M0630, Grooming_M0640, Grooming_M0640p, Dress_Upper_M0650, Dress_Upper_M0650p, Dress_Lower_M0660, Dress_Lower_M0660p, Bathing_M0670, Bathing_M0670p, Toileting_M0680, Toileting_M0680p, Transferring_M0690, Transferring_M0690p, Ambulation_M0700, Ambulation_M0700p, Eating_M0710, Eating_M0710p, Meal_Prep_M0720p, Transport_M0730, Transport_M0730p, Laundry_M0740, Laundry_M0740p, Housekeeping_M0750, Housekeeping_M0750p, Shopping_M0760, Shopping_M0760p, Use_Phone_M0770, Use_Phone_M0770p, Oral_Meds_M0780, Oral_Meds_M0780p, Inhalant_Meds_M0790, Inhalant_Meds_M0790p, Inject_Meds_M0800, Inject_Meds_m0800p, Patient_Manage_Equip_M0810, Caregiver_Manage_Equip_M0820, Therapy_Need_M0825, Emergent_Care_M0830, ASSESSMENT_NOTE, Record_Created_By, Transmission_status FROM #Request.prefix_db_agency#.Assessment_New where Assessment_ID='#session.cs.AssessmentId#' select Last_Name,First_Name from #Request.prefix_db_lookup#.Employee where Employee_ID = '#AssForm.Record_Created_By#' pat = CreateObject("Component", "assessment"); get_pain_que = pat.get_pain_ques('1 - Start of care - further visits planned','pain');

#DateFormat(AssForm.Start_of_Care_M0030,'mm/dd/yyyy')# - Psychiatric Eval Form

Other Services Involved (By Current Agency)

Other Agencies Involved

Nutritional Therapies

checked /> 1 - Intravenous or Infusion Therapy (excludes TPN) checked /> 2 - Parenteral Nutrition (TPN or liquids) checked /> 3 - Enteral Nutrition (Nasogastric, Gastrostomy, Jejunostomy, etc) checked /> 4 - None of the above

No Pain Pain Assessment Pain assessment incomplete

Gastrointestinal

checked /> Abnormal Stool Lab checked /> Bowel Sounds not Soft Gurgling 5-35/min checked /> Constipation checked /> Diarrhea checked /> Excoriation of Surrounding Skin checked /> Asymptomatic checked /> Other

Home Health Aide Indicators

checked /> Light Housekeeping Needed checked /> Light Meal Prep Needed checked /> Shopping Needed checked /> Errands Needed checked /> Companionship Needed checked /> Caregiver Respite Needed checked /> Emotional Support Needed checked /> Other

Comments

mood

affect

orientation

dysfunctional thoughts

appearance/hygiene

perceptions

psychomotor behavior

communication

suicidal/homicidal ideation

coping abilities

functional level

Other

hyperverbal