English French Notes Complete/Exclude 1. Highest educational level attained: 2. Special educational training or skills: Is not, or unknown if currently enrolled in an educational program or trade school. 4. Educational Assesment: IV. Military History: 1. Period of Service: 4. Service Connected Disability: 5. Military Assessment: V. Social/Family Relationship: 1. Marital status: SOCIAL WORK SERVICE-REPORTS AND SUMMARIES 4. Describe Social Support System: 5. Present use of Community Resources: 6. Current Living arrangements: 7. Social/Family Assessment: VI. Legal Situation: Power of Attorney: Living Will: Guardianship: Legal Assessment: VII. Current Substance Abuse Problems: Comments on Substance Abuse: VIII. Psycho-Social Assessment: IX. Preliminary List of Problems Initial Plan of Action 3. MILITARY HISTORY 4. SOCIAL/FAMILY RELATIONSHIPS 5. LEGAL SITUATION 6. CURRENT SUBSTANCE ABUSE 7. PRELIMINARY PROBLEMS 8. PSYCHO-SOCIAL ASSESSMENT Enter number(s) to enter/edit i.e => 1 or 1,8 or All or Do you want to print Assessment data Enter the number of the category for this patient you want to enter/edit. For example if you want to enter/edit the categories Enter the number i.e. 2,3 separated by comma or enter any combination of numbers separated by commas or if all categories are to be edited, press carriage return for default of . VALID NUMBERS ARE 1-8. INVALID CATEGORY NUMBER(s) ! Do you want to try again CLINICAL SUPERVISOR'S REPORT Task Queued to Print ! PG. CLINICAL SUPERVISORY REPORT PLANNING DATE NOTE DATE 1. CLOSING NOTES 2. DISCHARGE PLANNING ENTER 1, 2 OR 'ALL' FOR BOTH NOTES TO PRINT or '^' to EXIT: CLOSING NOTE: AFTER CARE PLAN: OPEN DATE: CLOSED DATE: NOTE ENTERED: SERVICES OFFERED: DISCHARGE PLAN: DISCHARGE PLAN ENTERED: CLOSING DISCHARGE PLANNING WARD/BED: PROBLEMS: INITIAL PLAN OF ACTION: SELECT SURROGATE SUPERVISOR: SELECT SURROGATED SUPERVISOR: YOU CANNOT BE YOUR OWN SURROGATE ! DO YOU WANT TO TRY AGAIN DIRECT SERVICES PROVIDED FROM: DIRECT SERVICES REPORT DIRECT SERVICES CATEGORY FOR COMPLETE SERVICE Do you want Complete Service Enter 'YES' to print the complete service. Do you want report by Supervisor Enter 'YES' to print the report by supervisor Enter Supervisor's last name To print the report for a supervisor, enter the supervisor's last name. Enter Social Worker's last name To print the report for a worker, enter the worker's last name. 'Y' for Yes 'N' for No Enter RCH: INQUIRY INTO RCH FILE REPORT RCH HOME REGISTRY FOR A SINGLE HOME: 1. ALL HOMES 2. A SINGLE HOME ? ENTER 1 or 2 1// ENTER RCH: RESIDENTIAL CARE HOME REPORT Enter the number one (1) if all homes are to print, else enter the number two (2) for an individual home. Do you want to screen Now (One to seven days) Enter 'YES' to run current date or up to seven days in the past. There were no possible High-Risk patients found for SOCIAL WORK SERVICE ! or OLDER - NSC INSURANCE COVERAGE - FEMALE - AGE 70 or greater and 2 or more OPT clinics - GENERAL DELIVERY GENERAL DELIVERY ADDRESS - NO ADDRESS - NO TEMPORARY ADDRESS - HIGH-RISK WARD - IRREGULAR DISCHARGE - READMITTED WITHIN ONE MONTH - PREVIOUS SPECIAL POPULATION PATIENT - HOME DIALYSIS - HBHC - SCI HOME CARE - OTHER HOME BASED PROGRAMS - ADMISSION DUE TO ACCIDENT - INCOME LESS THAN LOCAL AMOUNT SEEN BY SOCIAL WORK & LOCATION RCH or CNH - OPENED: SOCIAL WORK HIGH RISK SCREENING PROFILE WORKER: SOCIAL WORKER: CASE NOT OPENED TO SOCIAL WORK SERVICE DATE ADMITTED: DATE SCREENED:____________ PATIENT ADDRESS: PATIENT ADDRESS UNAVAILABLE NOK NAME: NOK ADDRESS: ADDITIONAL CONTACTS: MARITAL STATUS: EMPLOYMENT STATUS: INSURANCE COVERAGE: VETERANS STATUS: HB SC CONDITION: ADMISSION DIAGNOSIS: LOCATION LAST VA TREATMENT: POSITIVE SCREENING CRITERIA: SOCIAL WORKER ASSESSMENT & PLAN: ROOM NO.: Social Worker UNEARNED INCOME (Current): DISABILITY PAYMENT HB AMOUNT VA PENSION INCOME SCREENING ( INTEREST,DIVIDEND,ANNUITY SOCIAL SECURITY (Includes SSI) WORKERS COMP OR BLACK LUNG *ALL OTHER INCOME TOTAL INCOME: *-This total may include amounts already listed under current 'UNEARNED INCOME'. BEGINNING SCREEN DATE: This report is formatted for 80 columns and must be sent to a printer. MANUAL HIGH-RISK SCREENING REPORT HOME DIAYLSIS - Do you want Complete Service THERE IS NOTHING TO REPORT FOR LOCATION OF PATIENTS BY COST CENTERS THERE IS NOTHING TO REPORT ON AMIS LOCATIONS FOR SUPERVISOR SOCIAL WORKER LOCATION OF PATIENTS BY COST CENTERS SOCIAL WORK DIVISIONAL LOCATION OF PATIENTS BY COST CENTERS REPORT COMPLETE SERVICE for DIVISION PATIENT INQUIRY REPORT DELETING SW POSITIONS FILE (#654) XMQ-SWA XMQ-SWM XMQ-SWK INSTALLING SECURITY KEY ' ' FOR SOCIAL WORK DATA TRANSMISSION HOLDERS WILL HAVE TO BE ADDED INSTALLING RELAY DOMAIN 'Q-SWA.VA.GOV' FOR SOCIAL WORK DATA TRANSMISSION... INSTALLING RELAY DOMAIN 'Q-RHC.VA.GOV' FOR SOCIAL WORK DATA TRANSMISSION... INSTALLING MAIL GROUP 'SWA' TO RECEIVE SOCIAL WORK TRANSMISSION CONFIRMATION... MEMBERS WILL HAVE TO BE ADDED... INSTALLING RELAY DOMAIN 'Q-SWM.VA.GOV' FOR SOCIAL WORK DATA TRANSMISSION... INSTALLING MAIL GROUP 'RHC' TO RECEIVE SOCIAL WORK TRANSMISSION CONFIRMATION... INSTALLING MAIL GROUP 'SWM' TO RECEIVE SOCIAL WORK TRANSMISSION CONFIRMATION... Are You: 1. Adding and Replacing a Worker Enter 1 or 2 1// SELECT NEW WORKER: INCOMPLETE WORKER INFORMATION!! DATA NOT ADDED. WHICH WORKER TO REPLACE ? ARE YOU SURE YOU WANT TO REPLACE THIS WORKER REPLACEMENT WORKER ? WORKERS INFORMATION MUST BE COMPLETE Entering the number one (1) will allow you to add a new worker and then assign that new worker a current worker's case load. The number two (2) allows you to assign a current worker's case load to another current worker. PLEASE ENTER SOCIAL WORK SITE PARAMETERS !!! SELECT DIVISION: Open date CASE FOR IS ALREADY OPENED BY HOMES MUST BE ADDED. THIS ENTRY WILL BE DELETED DO YOU WANT TO CLOSE CASE DO YOU WANT TO OPEN ANOTHER NEW CASE Was this a High Risk Patient SELECT HOME: INCOMPLETE DATA!! RECORD DELETED. DELETING OLD NAMESPACE (SW) SORT TEMPLATES... Sort Template... DELETING OLD NAMESPACE (SW) INPUT TEMPLATES... Input Temple... DELETING OLD NAMESPACE (SW) PRINT TEMPLATES... Print Template... DELETING OLD NAMESPACE (SW) OPTIONS... Menu Option... DELETING OBSOLETE OPTIONS... Option to re-index the 'CP' and 'BS5' x-refs in file #650 Option QUEUED to run BE SURE LABELS ARE IN PRINTER PROPERLY WHEN READY PRESS RETURN OR ENTER KEY. ARE YOU READY RESIDENTIAL CARE HOME ADDRESS LIST LABELS WILL PRINT LATER Problems and Outcomes Report NOT ATTAINED PROB. NOT TO TREAT CR BARR. VAMC BARR. NOTE: P/F=PATIENT/FAMILY, CR=COMMUNITY RESOURCES, BARR.=BARRIERS DIVISONAL PROBLEMS AND OUTCOME REPORT NOTE: P/F=PATIENT/FAMILY, CR=COMMUNITY RESOURCES, BARR.=BARRIERS PRINT ALL AMIS REPORTS OPTION RCH PATIENT REGISTRY FOR ALL OPEN CASES FOR A SINGLE WORKER COMPLETE: OPEN CASES SUMMARY: OPEN CASES RCH PATIENT REGISTRY FOR ALL CASES PATIENT STATUS REPORT RESOURCES/REFERRALS THERE IS DATA IN THE SOCIAL WORK CASE FILE. DO YOU WANT TO CONTINUE INSTALLATION TERMINATED ! DO YOU WANT TO DELETE OLD NAMESPACE (SW) TEMPLATES AND OPTIONS NOW IF 'YES' ALL SOCIAL WORK CASE DATA WILL BE DELETED. IF 'NO' THE INSTALL WILL TERMINATE, BUT ALL CASES MUST BE CLOSED, TRANSMITTED TO AUSTIN, AND CASE DATA MUST BE PURGED. RCH PATIENT REGISTRY FOR ALL OPEN CASES Ending date must be after starting date QUALITY MGMT. MONITOR I REPORT - SOCIAL WORK DISCHARGE PLANNING FAMILY CONFERENCE Quality Management Monitor II Family involvement in Discharged Planning Total Patients Family Conference % rec'd Family Conference QUALITY MGMT. MONITOR III REPORT - SOCIAL WORK Quality Management Monitor III Timeliness of service to patients receiving discharge planning # PTS REC'D DISCH. PLAN. AVG. # ELAPSED DAYS QUALITY MGMT. MONITOR IV REPORT - SOCIAL WORK Quality Management Monitor IV Level of problem resolution by problem code Worker's #: Resolutions Occurred QUALITY MGMT. MONITOR V REPORT - SOCIAL WORK Quality Management Monitor V Access to Social Work Services by Location Total # Patients Treatment Episodes POST DISCHARGE FOLLOW-UP Quality Management Monitor I Follow-up of discharged inpatients who received Discharged Planning and had Problems related to care Post Discharge Follow-up QUALITY MGMT. REVIEW I REPORT - SOCIAL WORK Quality Management Review I Non-Followup of discharged inpatients who received Date Opened QUALITY MGMT. REVIEW III REPORT - SOCIAL WORK Avg. # Elapsed Days: Quality Management Review III Worker's # Elapsed Days QUALITY MANAGEMENT REVIEW IV REPORT - SOCIAL WORK Quality Management Review IV Unresolved problems QUALITY MGMT. REVIEW II REPORT - SOCIAL WORK Quality Management Review II RCH AMIS 256 FROM RESIDENTIAL CARE HOME AMIS REPORT CASES OPENED DURING QUARTER CASES CLOSED DURING QUARTER TOTAL CASES TREATED PREVIOUS LIVING ARRANGEMENTS VA CARE VAH EXCESS VA DOM VA CNH VA NH VA RES. NON NH LEVEL OF CARE CAPACITY SPECIAL PATIENT POPULATION RCS AMIS REPORT 10-0173 RCS 10-0173 AMIS REPORT #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### #################### ####################