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GIMG Cognitive Assessment Visit

Step 1 of 11

9%
Route Sheet
ROUTE SHEET
COGNITIVE ASSESSMENT
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Address
Clear Signature
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Clear Signature
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Clear Signature
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Medication Reconciliation
MEDICATION RECONCILIATION
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Sex:
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
1
26
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
2
27
 
List
3
28
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
4
29
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
5
30
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
6
31
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
7
32
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
8
33
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
9
34
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
10
35
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
11
36
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
12
37
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
13
38
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
14
39
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
15
40
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
16
41
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
17
42
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
18
43
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
19
44
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
20
45
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
21
46
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
22
47
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
23
48
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
24
49
 
CURRENT MEDICATIONS / DOSE / ROUTE / FREQUENCY
25
50
 
Clear Signature
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Cognitive Assessment Visit
COGNITIVE ASSESSMENT VISIT
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Sex:
TELEHEALTH/HOME VISIT
Is patient able to provide a complete and reliable medical history?
Is an independent historian present that can provide a complete and reliable medical history?

VITALS

SAFETY & SOCIAL SUPPORT:

Is patient bedbound?
Does patient use an assistive device?
Does patient have social support at home?
Is patient’s social support knowledgeable of, and understands patient’s illness?
Is patient’s social support willing to provide the care that patient requires?
Does patient’s social support require education / training?
Does patient require additional social support?
EVALUATION FOR HOME AND MOTOR VEHICLE OPERATION

ASSESSMENT OF BASIC AND INSTRUMENTAL ACTIVITIES OF DAILY LIVING:

Patient is unable to independently do the following:
Cognitive Assessment Visit
COGNITIVE ASSESSMENT VISIT
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Sex:
DEPRESSION SCREENING:

Mark each question with the appropriate number. When completed, see recommendation based on total.

Over the last 2 weeks, how often have you felt the following?

Not at all = 0 Several days = 1 More than a week = 2 Nearly every day = 3
Little interest or pleasure in doing things
Feeling down, depressed or hopeless
Feeling tired or having little energy
Poor appetite or overeating
Trouble falling or staying asleep, or sleeping too much
Feeling bad about yourself or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading or watching tv
Moving or speaking so slowly that other people noticed or being so fidgety or restless that you have been moving a lot more than usual
Thoughts that you would be better off dead or of hurting yourself in some way
TOTAL
ANXIETY SCREENING:

Mark each question with the appropriate number. When completed, see recommendation based on total.

Over the last 2 weeks, how often have you felt the following?

Not at all = 0 Several days = 1 More than a week = 2 Nearly every day = 3
Feeling nervous
Not being able to stop or control worrying
Worrying too much about different things
4) Trouble relaxing
Being so restless that it’s hard to sit still
Becoming easily annoyed or irritable
Feeling afraid, as if something awful might happen
TOTAL
Cognitive Assessment Visit
COGNITIVE ASSESSMENT VISIT
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Sex:
PATIENT EXAMINATION MINI-COG (if patient is not capable of answering, proceed to AD8)
Patient is unable to answer

Step 1: Word Registration:

“Please listen carefully, I am going to say three words that I want you to repeat back to me now and try to remember. The words are: (select a version below). Please say them back to me now” (If patient is unable to repeat the words back, then move on to clock drawing)

Version 1
Black
Apple
Dog

Version 2
Blue
Mango
Cat

Version 3
Red
Banana
Fish

Version 4
Green
Lemon
Bird

Step 2: Day/Time orientation:

“Do you know what year it is?”
“Do you know what month?”
“Do you know what day it is?”

Step 3: Clock Drawing:

“Next I want you to draw a clock for me. Please put all of the numbers where they go”
“Next please draw the hands to show 10:15”

Step 4: Information

“Can you tell me something that happened in the news recently or something that you did last week?”

Step 5: Recall

“What were the 3 words I asked you to remember?”
Word 1
Word 2
Word 3

If patient scores 9 correctly, no significant cognitive impairment and further testing is not necessary.

If patient scores 5 – 8 correctly, more information required, proceed to AD8 Examination.

If patient scores of 0 – 4 correctly, Cognitive impairment is indicated, proceed to AD8 Examination.

Cognitive Assessment Visit
COGNITIVE ASSESSMENT VISIT
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Sex:

AD8 DEMENTIA SCREENING INTERVIEW (Administered to either the independent historian, preferable, or the patient):

“YES, a change” indicates there has been a change in the last several years caused by cognitive (thinking and memory) problems.

Problem with judgment (problems making decisions, bad financial decisions, problems with thinking)
Less interest in hobbies / activities
Repeats the same things over and over (questions, stories or statements)
Trouble learning how to use a tool, appliance, or gadget (computer, microwave, remote control)
Forgets correct month or year
Trouble learning how to use a tool, appliance, or gadget (computer, microwave, remote control)
Trouble remembering appointments
Daily problems with thinking and/or memory

0 – 1 “Yes”: Normal Cognition

2 or greater “Yes” or “Don’t Know”: Cognitive impairment is likely to be present

FUNCTIONAL ASSESSMENT STAGING TOOL (FAST)

STAGE 1
ASSESSMENT (score is highest consecutive level of disability)
STAGE 2
ASSESSMENT (score is highest consecutive level of disability)
STAGE 3
ASSESSMENT (score is highest consecutive level of disability)
STAGE 4
ASSESSMENT (score is highest consecutive level of disability)
STAGE 5
ASSESSMENT (score is highest consecutive level of disability)
STAGE 6A
ASSESSMENT (score is highest consecutive level of disability)
STAGE 6B
ASSESSMENT (score is highest consecutive level of disability)
STAGE 6C
ASSESSMENT (score is highest consecutive level of disability)
STAGE 6D
ASSESSMENT (score is highest consecutive level of disability)
STAGE 6E
ASSESSMENT (score is highest consecutive level of disability)
STAGE 7A
ASSESSMENT (score is highest consecutive level of disability)
STAGE 7B
ASSESSMENT (score is highest consecutive level of disability)
STAGE 7C
ASSESSMENT (score is highest consecutive level of disability)
STAGE 7D
ASSESSMENT (score is highest consecutive level of disability)
STAGE 7E
ASSESSMENT (score is highest consecutive level of disability)
STAGE 7F
ASSESSMENT (score is highest consecutive level of disability)
Cognitive Assessment Visit
COGNITIVE ASSESSMENT VISIT
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Sex:

Clinical Dementia Rating

IMPAIRMENT
MEMORY
ORIENTATION
JUDGEMENT & PROBLEM SOLVING
COMMUNITY AFFAIRS
HOME & HOBBIES
PERSONAL CARE

0.0 – Normal

0.5 – 2.5 – Questionable Cognitive Impairment

3.0 – 4.0 – Very Mild Dementia

4.5 – 9.0 – Mild Dementia

9.5 – 15.5 – Moderate Dementia

16.0 – 18.0 – Severe Dementia

Cognitive Assessment Visit
COGNITIVE ASSESSMENT VISIT
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Sex:
List
PROBLEM
GOAL
PLAN AND MANAGEMENT
 
List
PROBLEM
GOAL
PLAN AND MANAGEMENT
 
List
PROBLEM
GOAL
PLAN AND MANAGEMENT
 
List
PROBLEM
GOAL
PLAN AND MANAGEMENT
 
List
PROBLEM
GOAL
PLAN AND MANAGEMENT
 
List
PROBLEM
GOAL
PLAN AND MANAGEMENT
 
List
PROBLEM
GOAL
PLAN AND MANAGEMENT
 
List
PROBLEM
GOAL
PLAN AND MANAGEMENT
 
Patient’s cognitive health in general:
COGNITIVE IMPAIRMENT DIAGNOSIS(ES) WITH ICD-10 CODES
Cognitive Assessment Visit
COGNITIVE ASSESSMENT VISIT
MM slash DD slash YYYY
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Sex:
Cognitive Assessment Visit
COGNITIVE ASSESSMENT VISIT
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Sex:

REFERRAL & ORDERS

Neurologist
Behavioral Therapist / Psychologist
Psychiatrist
Adult Day Care
Home Health
Medical Management
Social Worker
Speech Therapist
Occupational Therapist
Home Health Aide
Other:
ADVANCE CARE PLANNING (ACP)
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Sex:

I understand that the Federal Patient Self-Determination Act of 1990 requires that I be made aware of my right to make Healthcare decisions for myself. I understand that I may express my wishes in various documents so that my wishes may be known when I am unable to speak for myself or make decisions on my own.

Consent
Consent
Consent
Consent
Consent
Consent
Consent
Consent
Consent
Consent
When I am dying, where practicable, I would prefer to be cared for at:
When I am dying, where practicable, I would like the following treatments:
I would like the following life sustaining measures, if practicable:
I have the following requests to be carried out after I die:
Clear Signature
MM slash DD slash YYYY