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_New.Date_Most_Recent_M0903, Assessment_New.Braden_1_Sensory, Assessment_New.Braden_2_Moisture, Assessment_New.Braden_3_Activity, Assessment_New.Braden_4_Mobility, Assessment_New.Psy_Nursing_M0630, Assessment_New.Grooming_M0640, Assessment_New.Grooming_M0640p, Assessment_New.Dress_Upper_M0650, Assessment_New.Dress_Upper_M0650p, Assessment_New.Dress_Lower_M0660, Assessment_New.Braden_5_Nutrition, Assessment_New.Braden_6_Friction, Assessment_New.M1730a, Assessment_New.M1730b, Assessment_New.Pain1, Assessment_New.Pain2, Assessment_New.Pain3, Assessment_New.Pain4, Assessment_New.Pain5, Assessment_New.Fall_A, Assessment_New.Fall_B, Assessment_New.Fall_C, Assessment_New.Fall_D, Assessment_New.Fall_E, Assessment_New.Fall_F, Assessment_New.Fall_G, Assessment_New.Fall_H, Assessment_New.Fall_I, Assessment_New.M1000_Other, Assessment_New.M2100a_Equip, Assessment_New.M2100b_Equip, Assessment_New.M2100c_Equip, Assessment_New.M2100d_Equip, Assessment_New.M2100e_Equip, Assessment_New.M2100f_Equip, Assessment_New.M2100g_Equip, Assessment_New.M1040_Influ, Assessment_New.M1045_Influ, Assessment_New.M2400a_Diabetic, Assessment_New.M2400b_FallsPrev, Assessment_New.M2400c_Depress, Assessment_New.M2400d_Pain, Assessment_New.M2400e_PressUlc, Assessment_New.M2400f_PressUlcMoist, Assessment_New.Assessment_note, Assessment_New.Assessment_Tracker_ID FROM #Request.prefix_db_agency#.Assessment_New WHERE Assessment_New.Assessment_ID='#session.cs.AssessmentId#'
#GetP.First_Name# #GetP.Last_Name#, ST - Evalution 0% done
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Safe Swallowing Evaluation Date
Facility
MD
Current Diet
Liquids
Comments
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Vital
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Type Temperature
Heart Rate
Respiratory Rate
Blood Pressure Systolic
Blood Pressure Diastolic
Blood Sugar Level
Weight
Height
Pain (scale 1-10)
Abdominal Girth
Head Circumference
O2 Saturation
Reading
Severity 0 asymptomatic
1 well-controlled
2 controlled with difficulty
3 poorly controlled
4 hx hospitalizations
Notes
#GetP.First_Name# #GetP.Last_Name#, ST - Evaluation 0% done
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Pain Assessment
Pain Level
style="background-color:#CCCCFF">
checked/> pain level 0 (low) checked/> pain level 6 (med)
checked/> pain level 1 (low) checked/> pain level 7 (high)
checked/> pain level 2 (low) checked/> pain level 8 (high)
checked/> pain level 3 (med) checked/> pain level 9 (high)
checked/> pain level 4 (med) checked/> pain level 10 (high)
checked/> pain level 5 (med) checked/> Other...
Pain Scale
0
1
2
3
4
5
Pain Characteristics
style="background-color:#CCCCFF">
checked/> Throbbing
checked/> Aching
checked/> Shooting
checked/> Stabbing
checked/> Burning
checked/> Not Applicable
checked/> Sharp
checked/> Numb
checked/> Other...
Pain Threshold
style="background-color:#CCCCFF">
checked/> at rest
checked/> with minimal activity
checked/> with moderate activity
checked/> with strenuous activity
checked/> Not Applicable
Rate CURRENT pain
treatment effectiveness
on a scale* of 1 to 10
(1 = low effectiveness)
style="background-color:#CCCCFF">
checked/> 1
checked/> 2
checked/> 3
checked/> 4
checked/> 5 		checked/> 6
checked/> 7
checked/> 8
checked/> 9
checked/> 10
How long does each
treatment work before
needing another dose
style="background-color:#CCCCFF">
checked/> 30 minute checked/> 6 hour
checked/> 1 hour checked/> 12 hour
checked/> 2 hour checked/> 24 hour
checked/> 3 hour
 checked/> More than 24 hours
checked/> 4 hour checked/> Not Applicable
What is patient's opinion
of the cause of her/his
pain?
style="background-color:#CCCCFF">
checked/> physical activity
checked/> disease process
checked/> Not Applicable
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Cognition
Short term memory
style="background-color:#CCCCFF"> checked id="Shortterm" value="0 - unable"> 0 - unable
checked id="Shortterm" value="1 - severe impairment"> 1 - severe impairment
checked id="Shortterm" value="2 - moderate impairment"> 2 - moderate impairment
checked id="Shortterm" value="3 - mild impairment"> 3 - mild impairment
checked id="Shortterm" value="4 - within functional limits"> 4 - within functional limits
long term memory
style="background-color:#CCCCFF"> checked id="longterm" value="0 - unable"> 0 - unable
checked id="longterm" value="1 - severe impairment"> 1 - severe impairment
checked id="longterm" value="2 - moderate impairment"> 2 - moderate impairment
checked id="longterm" value="3 - mild impairment"> 3 - mild impairment
checked id="longterm" value="4 - within functional limits"> 4 - within functional limits
Orientation
style="background-color:#CCCCFF"> checked id="Orientation" value="0 - unable"> 0 - unable
checked id="Orientation" value="1 - severe impairment"> 1 - severe impairment
checked id="Orientation" value="2 - moderate impairment"> 2 - moderate impairment
checked id="Orientation" value="3 - mild impairment"> 3 - mild impairment
checked id="Orientation" value="4 - within functional limits"> 4 - within functional limits
Attention Span
style="background-color:#CCCCFF"> checked id="Attention" value="0 - unable"> 0 - unable
checked id="Attention" value="1 - severe impairment"> 1 - severe impairment
checked id="Attention" value="2 - moderate impairment"> 2 - moderate impairment
checked id="Attention" value="3 - mild impairment"> 3 - mild impairment
checked id="Attention" value="4 - within functional limits"> 4 - within functional limits
Comments
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Reading
Letter/numbers
style="background-color:#CCCCFF"> checked id="ReadingLetter" value="0 - unable"> 0 - unable
checked id="ReadingLetter" value="1 - severe impairment"> 1 - severe impairment
checked id="ReadingLetter" value="2 - moderate impairment"> 2 - moderate impairment
checked id="ReadingLetter" value="3 - mild impairment"> 3 - mild impairment
checked id="ReadingLetter" value="4 - within functional limits"> 4 - within functional limits
Words
style="background-color:#CCCCFF"> checked id="ReadingWords" value="0 - unable"> 0 - unable
checked id="ReadingWords" value="1 - severe impairment"> 1 - severe impairment
checked id="ReadingWords" value="2 - moderate impairment"> 2 - moderate impairment
checked id="ReadingWords" value="3 - mild impairment"> 3 - mild impairment
checked id="ReadingWords" value="4 - within functional limits"> 4 - within functional limits
Simple sentences
style="background-color:#CCCCFF"> checked id="ReadingSimple" value="0 - unable"> 0 - unable
checked id="ReadingSimple" value="1 - severe impairment"> 1 - severe impairment
checked id="ReadingSimple" value="2 - moderate impairment"> 2 - moderate impairment
checked id="ReadingSimple" value="3 - mild impairment"> 3 - mild impairment
checked id="ReadingSimple" value="4 - within functional limits"> 4 - within functional limits
Complex sentences
style="background-color:#CCCCFF"> checked id="ReadingComplex" value="0 - unable"> 0 - unable
checked id="ReadingComplex" value="1 - severe impairment"> 1 - severe impairment
checked id="ReadingComplex" value="2 - moderate impairment"> 2 - moderate impairment
checked id="ReadingComplex" value="3 - mild impairment"> 3 - mild impairment
checked id="ReadingComplex" value="4 - within functional limits"> 4 - within functional limits
Paragraph
style="background-color:#CCCCFF"> checked id="ReadingParagraph" value="0 - unable"> 0 - unable
checked id="ReadingParagraph" value="1 - severe impairment"> 1 - severe impairment
checked id="ReadingParagraph" value="2 - moderate impairment"> 2 - moderate impairment
checked id="ReadingParagraph" value="3 - mild impairment"> 3 - mild impairment
checked id="ReadingParagraph" value="4 - within functional limits"> 4 - within functional limits
Comments
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Writing
Letter/numbers
style="background-color:#CCCCFF"> checked id="WritingLetter" value="0 - unable"> 0 - unable
checked id="WritingLetter" value="1 - severe impairment"> 1 - severe impairment
checked id="WritingLetter" value="2 - moderate impairment"> 2 - moderate impairment
checked id="WritingLetter" value="3 - mild impairment"> 3 - mild impairment
checked id="WritingLetter" value="4 - within functional limits"> 4 - within functional limits
Words
style="background-color:#CCCCFF"> checked id="WritingWords" value="0 - unable"> 0 - unable
checked id="WritingWords" value="1 - severe impairment"> 1 - severe impairment
checked id="WritingWords" value="2 - moderate impairment"> 2 - moderate impairment
checked id="WritingWords" value="3 - mild impairment"> 3 - mild impairment
checked id="WritingWords" value="4 - within functional limits"> 4 - within functional limits
Simple sentences
style="background-color:#CCCCFF"> checked id="WritingSimple" value="0 - unable"> 0 - unable
checked id="WritingSimple" value="1 - severe impairment"> 1 - severe impairment
checked id="WritingSimple" value="2 - moderate impairment"> 2 - moderate impairment
checked id="WritingSimple" value="3 - mild impairment"> 3 - mild impairment
checked id="WritingSimple" value="4 - within functional limits"> 4 - within functional limits
Complex sentences
style="background-color:#CCCCFF"> checked id="WritingComplex" value="0 - unable"> 0 - unable
checked id="WritingComplex" value="1 - severe impairment"> 1 - severe impairment
checked id="WritingComplex" value="2 - moderate impairment"> 2 - moderate impairment
checked id="WritingComplex" value="3 - mild impairment"> 3 - mild impairment
checked id="WritingComplex" value="4 - within functional limits"> 4 - within functional limits
Paragraph
style="background-color:#CCCCFF"> checked id="WritingParagraph" value="0 - unable"> 0 - unable
checked id="WritingParagraph" value="1 - severe impairment"> 1 - severe impairment
checked id="WritingParagraph" value="2 - moderate impairment"> 2 - moderate impairment
checked id="WritingParagraph" value="3 - mild impairment"> 3 - mild impairment
checked id="WritingParagraph" value="4 - within functional limits"> 4 - within functional limits
Comments
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Speech/Voice
Articulation
style="background-color:#CCCCFF"> checked id="Articulation" value="0 - unable"> 0 - unable
checked id="Articulation" value="1 - severe impairment"> 1 - severe impairment
checked id="Articulation" value="2 - moderate impairment"> 2 - moderate impairment
checked id="Articulation" value="3 - mild impairment"> 3 - mild impairment
checked id="Articulation" value="4 - within functional limits"> 4 - within functional limits
Prosody
style="background-color:#CCCCFF"> checked id="Prosody" value="0 - unable"> 0 - unable
checked id="Prosody" value="1 - severe impairment"> 1 - severe impairment
checked id="Prosody" value="2 - moderate impairment"> 2 - moderate impairment
checked id="Prosody" value="3 - mild impairment"> 3 - mild impairment
checked id="Prosody" value="4 - within functional limits"> 4 - within functional limits
Voice/Respiration
style="background-color:#CCCCFF"> checked id="Respiration" value="0 - unable"> 0 - unable
checked id="Respiration" value="1 - severe impairment"> 1 - severe impairment
checked id="Respiration" value="2 - moderate impairment"> 2 - moderate impairment
checked id="Respiration" value="3 - mild impairment"> 3 - mild impairment
checked id="Respiration" value="4 - within functional limits"> 4 - within functional limits
Speech Intelligibility
style="background-color:#CCCCFF"> checked id="SpeechIntelligibility" value="0 - unable"> 0 - unable
checked id="SpeechIntelligibility" value="1 - severe impairment"> 1 - severe impairment
checked id="SpeechIntelligibility" value="2 - moderate impairment"> 2 - moderate impairment
checked id="SpeechIntelligibility" value="3 - mild impairment"> 3 - mild impairment
checked id="SpeechIntelligibility" value="4 - within functional limits"> 4 - within functional limits
Oral/facial exam
style="background-color:#CCCCFF"> checked id="Oralfacialexam" value="0 - unable"> 0 - unable
checked id="Oralfacialexam" value="1 - severe impairment"> 1 - severe impairment
checked id="Oralfacialexam" value="2 - moderate impairment"> 2 - moderate impairment
checked id="Oralfacialexam" value="3 - mild impairment"> 3 - mild impairment
checked id="Oralfacialexam" value="4 - within functional limits"> 4 - within functional limits
Comments
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Swallowing
Chewing ability
style="background-color:#CCCCFF"> checked id="Chewingability" value="0 - unable"> 0 - unable
checked id="Chewingability" value="1 - severe impairment"> 1 - severe impairment
checked id="Chewingability" value="2 - moderate impairment"> 2 - moderate impairment
checked id="Chewingability" value="3 - mild impairment"> 3 - mild impairment
checked id="Chewingability" value="4 - within functional limits"> 4 - within functional limits
Oral stage management
style="background-color:#CCCCFF"> checked id="Oralstagemanagement" value="0 - unable"> 0 - unable
checked id="Oralstagemanagement" value="1 - severe impairment"> 1 - severe impairment
checked id="Oralstagemanagement" value="2 - moderate impairment"> 2 - moderate impairment
checked id="Oralstagemanagement" value="3 - mild impairment"> 3 - mild impairment
checked id="Oralstagemanagement" value="4 - within functional limits"> 4 - within functional limits
Pharyngeal stage management
style="background-color:#CCCCFF"> checked id="Pharyngealstagemanagement" value="0 - unable"> 0 - unable
checked id="Pharyngealstagemanagement" value="1 - severe impairment"> 1 - severe impairment
checked id="Pharyngealstagemanagement" value="2 - moderate impairment"> 2 - moderate impairment
checked id="Pharyngealstagemanagement" value="3 - mild impairment"> 3 - mild impairment
checked id="Pharyngealstagemanagement" value="4 - within functional limits"> 4 - within functional limits
Reflex time
style="background-color:#CCCCFF"> checked id="Reflextime" value="0 - unable"> 0 - unable
checked id="Reflextime" value="1 - severe impairment"> 1 - severe impairment
checked id="Reflextime" value="2 - moderate impairment"> 2 - moderate impairment
checked id="Reflextime" value="3 - mild impairment"> 3 - mild impairment
checked id="Reflextime" value="4 - within functional limits"> 4 - within functional limits
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#ind#
Verbal Expression
Augmentative methods
style="background-color:#CCCCFF"> checked id="Augmentativemethods" value="0 - unable"> 0 - unable
checked id="Augmentativemethods" value="1 - severe impairment"> 1 - severe impairment
checked id="Augmentativemethods" value="2 - moderate impairment"> 2 - moderate impairment
checked id="Augmentativemethods" value="3 - mild impairment"> 3 - mild impairment
checked id="Augmentativemethods" value="4 - within functional limits"> 4 - within functional limits
Naming
style="background-color:#CCCCFF"> checked id="Naming" value="0 - unable"> 0 - unable
checked id="Naming" value="1 - severe impairment"> 1 - severe impairment
checked id="Naming" value="2 - moderate impairment"> 2 - moderate impairment
checked id="Naming" value="3 - mild impairment"> 3 - mild impairment
checked id="Naming" value="4 - within functional limits"> 4 - within functional limits
Appropriate Yes/No
style="background-color:#CCCCFF"> checked id="AppropriateYesNo" value="0 - unable"> 0 - unable
checked id="AppropriateYesNo" value="1 - severe impairment"> 1 - severe impairment
checked id="AppropriateYesNo" value="2 - moderate impairment"> 2 - moderate impairment
checked id="AppropriateYesNo" value="3 - mild impairment"> 3 - mild impairment
checked id="AppropriateYesNo" value="4 - within functional limits"> 4 - within functional limits
Complex sentences
style="background-color:#CCCCFF"> checked id="VerbalComplexsentences" value="0 - unable"> 0 - unable
checked id="VerbalComplexsentences" value="1 - severe impairment"> 1 - severe impairment
checked id="VerbalComplexsentences" value="2 - moderate impairment"> 2 - moderate impairment
checked id="VerbalComplexsentences" value="3 - mild impairment"> 3 - mild impairment
checked id="VerbalComplexsentences" value="4 - within functional limits"> 4 - within functional limits
Conversation
style="background-color:#CCCCFF"> checked id="Conversation" value="0 - unable"> 0 - unable
checked id="Conversation" value="1 - severe impairment"> 1 - severe impairment
checked id="Conversation" value="2 - moderate impairment"> 2 - moderate impairment
checked id="Conversation" value="3 - mild impairment"> 3 - mild impairment
checked id="Conversation" value="4 - within functional limits"> 4 - within functional limits
Comments
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#ind#
Auditory Comprehension
WordDiscrimination
style="background-color:#CCCCFF"> checked id="WordDiscrimination" value="0 - unable"> 0 - unable
checked id="WordDiscrimination" value="1 - severe impairment"> 1 - severe impairment
checked id="WordDiscrimination" value="2 - moderate impairment"> 2 - moderate impairment
checked id="WordDiscrimination" value="3 - mild impairment"> 3 - mild impairment
checked id="WordDiscrimination" value="4 - within functional limits"> 4 - within functional limits
1 Step Directions
style="background-color:#CCCCFF"> checked id="OneStepDirections" value="0 - unable"> 0 - unable
checked id="OneStepDirections" value="1 - severe impairment"> 1 - severe impairment
checked id="OneStepDirections" value="2 - moderate impairment"> 2 - moderate impairment
checked id="OneStepDirections" value="3 - mild impairment"> 3 - mild impairment
checked id="OneStepDirections" value="4 - within functional limits"> 4 - within functional limits
2 Step Directions
style="background-color:#CCCCFF"> checked id="TwoStepDirections" value="0 - unable"> 0 - unable
checked id="TwoStepDirections" value="1 - severe impairment"> 1 - severe impairment
checked id="TwoStepDirections" value="2 - moderate impairment"> 2 - moderate impairment
checked id="TwoStepDirections" value="3 - mild impairment"> 3 - mild impairment
checked id="TwoStepDirections" value="4 - within functional limits"> 4 - within functional limits
Complex Directions
style="background-color:#CCCCFF"> checked id="AuditoryComplexDirections" value="0 - unable"> 0 - unable
checked id="AuditoryComplexDirections" value="1 - severe impairment"> 1 - severe impairment
checked id="AuditoryComplexDirections" value="2 - moderate impairment"> 2 - moderate impairment
checked id="AuditoryComplexDirections" value="3 - mild impairment"> 3 - mild impairment
checked id="AuditoryComplexDirections" value="4 - within functional limits"> 4 - within functional limits
Conversation
style="background-color:#CCCCFF"> checked id="AuditoryConversation" value="0 - unable"> 0 - unable
checked id="AuditoryConversation" value="1 - severe impairment"> 1 - severe impairment
checked id="AuditoryConversation" value="2 - moderate impairment"> 2 - moderate impairment
checked id="AuditoryConversation" value="3 - mild impairment"> 3 - mild impairment
checked id="AuditoryConversation" value="4 - within functional limits"> 4 - within functional limits
Speech reading
style="background-color:#CCCCFF"> checked id="AuditorySpeechreading" value="0 - unable"> 0 - unable
checked id="AuditorySpeechreading" value="1 - severe impairment"> 1 - severe impairment
checked id="AuditorySpeechreading" value="2 - moderate impairment"> 2 - moderate impairment
checked id="AuditorySpeechreading" value="3 - mild impairment"> 3 - mild impairment
checked id="AuditorySpeechreading" value="4 - within functional limits"> 4 - within functional limits
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