COMPREHENSIVE MEDICAL ASSESSMENT FORM by grapieroo10

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									              COMPREHENSIVE MEDICAL ASSESSMENT FORM
    Complete a CMA form for all new residents within 6 weeks (preferably) of admission to a Residential Aged Care Facility and annually
    for existing residents. The resident’s carer may be able to provide useful information on matters such as medication usage and
    compliance, continence and physical, psychological and social function (subject to the resident’s agreement).



Residents Details

Surname:_________________________ Given Names:_________________________

Date of Birth:_______________________ Age:________________________________

Existing Resident:            Yes □ No □                       DVA No._____________________________

DVA Card Type:____________________ Pension No.___________________________

Medicare No.______________________ Medicare Number Expiry Date                                                     /      /

Next of Kin/Legal Guardian

Surname:_________________________ Given Names:_________________________

Home Phone: _____________________ Work:_______________________________

Mobile:___________________________

Consent
Has the resident and or representative signed a ‘consent form’ for the sharing of
information between other health care providers?        Yes □           No     □

Please ask specifically for consent to participate in a CMA, Care Planning, Case
Conferencing or RMMR as deemed necessary.

Resident/Representative Consent                                Yes □                 No □

Legal Information
Advanced Care Directive                                        Yes □                 No □
Palliative Care Order                                          Yes □                 No □
Enduring Power of Attorney                                     Yes □                 No □
Medical Power of Attorney                                      Yes □                 No □
Community Treatment Order                                      Yes □                 No □
Enduring Power of Guardianship                                 Yes □                 No □

CMA Service Details
Has the resident had a previous CMA?                           Yes □                 No □ Date of Last CMA                    /    /

Provided by Dr: _______________________ Contact No: _______________________

If doctor providing CMA is not the resident’s usual doctor, has the CMA report been
provided to the resident’s usual doctor?           Yes □          No   □

          1 Developed by the General Practice Network South Aged Care Panels – July 2005
If existing resident please indicate reason for CMA
First CMA for resident                                                           □
12 monthly CMA review                                                            □
Discharge from an acute care facility in the previous 4 weeks                    □
Significant changes to medication regimen in the last 3 months                   □

Diagnosis / Problem
Principal diagnoses / other significant health problems
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Resident’s Relevant Medical History
(May refer to current information from nursing home, information from residents records)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Current Medication - (prescribed and non-prescribed medication & complementary therapies)
(See attached copy of Medication Chart)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Allergies and Drug Intolerance
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Immunisation Status
- Tetanus         Current                 Yes    □        No     □       Date Given:       /   /
- Pneumococcus    Current                 Yes    □        No     □       Date Given:       /   /
- Annual Fluvax   Current                 Yes    □        No     □       Date Given:       /   /

Findings & Actions:
______________________________________________________________________
______________________________________________________________________

Alcohol                 Yes      □        No     □             Amount daily ________________
Smoking                 Yes      □        No     □             Number daily________________
Driving                 Yes      □        No     □
Fit to drive?           Yes      □        No     □

Nutritional Status/Dietary Requirements:
Special Diet        Yes □       No   □
Swallowing          Yes □       No   □

Findings & Actions:
_____________________________________________________________________
______________________________________________________________________

          2 Developed by the General Practice Network South Aged Care Panels – July 2005
Continence
Urinary              Yes     □       No     □
Faecal               Yes     □       No     □

Findings & Actions:
_____________________________________________________________________
______________________________________________________________________

EXAMINATION

Weight ___________ kg Height ___________ cm Urinalysis ___________

Ears/Nose/Throat
Hearing/Whisper Test         □       Hearing Aid     □      Dentures       □
Oral Health                  □

Findings & Actions:
_____________________________________________________________________
______________________________________________________________________

Cardiovascular
BP                   □       Pulse Rate             □       Rhythm            □
Peripheral Pulses    □       Murmur                 □       Peripheral Oedema □

Findings & Actions:
_____________________________________________________________________
______________________________________________________________________

Respiratory
Rate                 □       Cyanosis Peripheral □          Cyanosis Central       □
Finger Clubbing      □       Air Entry           □          Creps                  □
Rhonchi              □

Findings & Actions:
_____________________________________________________________________
______________________________________________________________________

Abdomen
Tenderness           □       Distension             □       Hepatomegaly           □
Splenomegaly         □       Masses                 □       Hernia                 □
Ascites              □       PR Exam                □

Findings & Actions:
_____________________________________________________________________
______________________________________________________________________


Central Nervous System
Paralysis              □             Speech         □               Tremor         □
Peripheral Neuropathy  □

        3 Developed by the General Practice Network South Aged Care Panels – July 2005
Findings & Actions:
_____________________________________________________________________
______________________________________________________________________

Mobility           Yes         □              No    □
Ataxia                         □              Hemiplegia      □       Paraplegia     □
Involuntary movement’s         □

Findings & Actions:
_____________________________________________________________________
______________________________________________________________________

Skin Integrity Normal                  Yes    □               No      □

Ulcer           □              Rash           □               Skin lesion            □

Findings & Actions:
_____________________________________________________________________
______________________________________________________________________

Pain
Acute                  Yes      □             No       □
Chronic                Yes      □             No       □

If yes, cause, site, severity of pain:
______________________________________________________________________
______________________________________________________________________

Palliative Care        Yes     □              No      □

Findings & Actions:
______________________________________________________________________
______________________________________________________________________

Mental Health
Cognition                      Mini Mental Score _______________

Assessment template included as required

Findings & Actions:
_____________________________________________________________________
______________________________________________________________________

Mood                      Depression Score _______________
Assessment template included as required

Findings & Actions:
______________________________________________________________________
______________________________________________________________________


          4 Developed by the General Practice Network South Aged Care Panels – July 2005
Other Mental Health Issues

Findings & Actions:
______________________________________________________________________
______________________________________________________________________

Falls past 6 months                Yes      □                No       □

Amount _______________                      Injuries _______________

Findings & Actions:
______________________________________________________________________
______________________________________________________________________

Issues for consideration in Medication Management
(swallowing difficulties, desire for self administration, cognitive function, dexterity)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Summary of outcomes of CMA (e.g. cardiovascular, respiratory, oral health, nutritional status)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Other Services Required
Residential Medication Management Review (MBS Item 903)                        Yes         □   No   □
Care Plan (MBS Item 731)                                                       Yes         □   No   □
Case Conference (MBS Item 734)                                                 Yes         □   No   □




GP Signature ___________________________________ Date ___________________


          5 Developed by the General Practice Network South Aged Care Panels – July 2005

								
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