10-10SH State Homes Program Application for Veterans Care Medica

OMB Approval No. 2900-0160
Estimated Burden: Avg. 30 min.

STATE HOME PROGRAM APPLICATION FOR VETERAN CARE
MEDICAL CERTIFICATION
PART I - ADMINISTRATIVE
STATE HOME FACILITY

DATE ADMITTED

GENDER
M

F

RESIDENT'S NAME (Last, First, Middle ) (This is a mandatory field)

SOCIAL SECURITY NUMBER. (Mandatory field)

RESIDENT'S STREET ADDRESS

AGE

CITY, STATE AND ZIP CODE

ADVANCED MEDICAL DIRECTIVE

DATE OF BIRTH (mm/dd/yyyy)

NO

YES

PART II - HISTORY AND PHYSICAL (Use separate sheet if necessary)
HISTORY

HEIGHT

WEIGHT

TEMP

PULSE

BP

HEAD/EYES/EAR/NOSE AND THROAT

NECK

CARDIOPULMONARY

ABDOMEN

GENITOURINARY

RECTAL

EXTREMITIES

NEUROLOGICAL

ALLERGY/DRUG SENSITIVITY

CHEST
X-RAY
X-RAY/
LAB

DATE (mm/dd/yyyy)

RESULTS

DATE (mm/dd/yyyy)

ALBUMEN

CBC

RESULTS

DATE (mm/dd/yyyy)

SEROLOGY
URINALYSIS

ACETONE

SUGAR

CHECK ALL BOXES THAT APPLY OR CHECK NA
IS DEMENTIA THE
PRIMARY DIAGNOSIS

YES

IS THERE A DIAGNOSIS OF MENTAL ILLNESS HAS RESIDENT RECEIVED MENTAL
SERVICES WITHIN THE PAST 2 YEARS

YES

NO

NO

YES

IS THERE ANY PRESSING EVIDENCE OF MENTAL ILLNESS SUCH AS:
PARANOIA
SCHIZOPHRENIA
SOMATOFORM DISORDER

MOOD SWINGS

IS CLIENT A DANGER TO SELF OR OTHERS

NO

YES

NO

OTHER PSYCHOTIC OR MENTAL DISORDERS LEADING TO CHRONIC DISABILITY
PANIC OR SEVERE ANXIETY DISORDER

PERSONALITY DISORDER

TUBE FEEDING

DECUBITUS ULCERS

MASK

PRN

OSTOMY

DRAINING WOUND

TEMPORARY

NASAL CANULAR

CONTINUOUS

TRACHOSTOMY

WOUND CULTURED

PERMANENT

OXYGEN

REFERRING PHYSICIAN

PRIMARY DIAGNOSIS

SECONDARY DIAGNOSIS

TERTIARY DIAGNOSIS

TYPE OF CARE RECOMMENDED:

SKILLED NURSING HOME CARE

DOMICILIARY CARE

FOLEY CATHETER

ADULT HEALTH CARE

HOSPITAL

MEDICATION AND TREATMENT ORDERS ON ADMISSION, CONTINUE ON SEPARATE SHEET IF NECESSARY

PRINTED OR TYPED NAME OF PRIMARY PHYSICIAN ASSIGNED

VA FORM
APR 2009

10-10SH

SIGNATURE OF PRIMARY PHYSICIAN ASSIGNED

EXISTING STOCK OF VA FORM 10-10SH, DATED JUL 1998, WILL BE USED.

PAGE 1

STATE HOME PROGRAM APPLICATION FOR VETERAN CARE - MEDICAL CERTIFICATION, CONTINUED

RESIDENT'S NAME (Last, First, Middle )

SOCIAL SECURITY NUMBER

EVALUATION (Select an appropriate number in each category)
COMMUNICATION

1. Transmits messages/receives information
2. Limited ability
3. Nearly or totaly unable

SPEECH

1. Speak clearly with others of same language
2. Limited ability
3. Unable to speak clearly or not at all

SIGHT

1. Good
2. Vision adequate - Unable to read/see details
3. Vision limited - Gross object differentiation
4. Blind

1. Good
2. Hearing slightly impaired
3. Nearly or totaly unable
4. Virtually/completely deaf

HEARING

TRANSFER

ENDURANCE

1. No assistance
2. Equipment only
3. Supervision only
4. Requires human transfer w/wo equipment
5. Bedfast

AMBULATION

1. Independence w/wo assistive device
2. Walks with supervision
3. Walks with continuous human support
4. Bed to chair (total help)
5. Bedfast

1. Tolerates distances (250 feet sustained activity)
2. Needs intermitten rest
3. Rarely tolerates short activities
4. No tolerance

MENTAL AND
BEHAVIOR
STATUS

1. Alert
2. Confused
3. Disoriented
4. Comatose

5. Agreeable
6. Disruptive
7. Apathetic
8. Well motivated

1. No assistance

A. Tub

2. Supervision Only

B. Shower

3. Assistance

C. Sponge bath

1. No assistance
2. Assistance to and from
and transfer
3. Total assistance including
personal hygiene,
help with clothes

TOILETING

A. Bathroom
B. Bedside
commode
C. Bedpan

DRESSING

1. Dresses self
2. Minor assistance
3. Needs help to complete dressing
4. Has to be dressed

BLADDER
CONTROL

1. Continent
2. Rarely incontinent
3. Occasional - once/week or less
4. Frequent - up to once a day
5. Total incontinence
6. Catheter, indwelling
1. Intact
2. Dry/Fragile
3. Irritations (Rash)
4. Open wound
5. Decubitus

SKIN
CONDITION

BATHING

4. Is bathed

FEEDING

1. No assistance
2. Minor assistance, needs tray set up only
3. Help feeding/encouraging
4. Is fed

BOWEL
CONTROL

1. Continent
2. Rarely incontinent
3. Occasional - once/week or less
4. Frequent - up to once a day
5. Total incontinence
6. Ostomy
1. Independence

Number

2. Assistance in difficult maneuvering

WHEEL CHAIR
USE

Stage

3. Wheels a few feet
NA

4. Unable to use
DATE

SIGNATURE OF REGISTERED NURSE OR REFERRING PHYSICIAN

PHYSICAL THERAPY (To be completed by Physical Therapist or Referring Physician)
SENSATION IMPAIRED RESTRICT ACTIVITY

YES

NO

YES

NEW REFERRAL

CONTINUATION OF THERAPY

PRECAUTIONS

NO

CARDIAC

FREQUENCY OF TREATMENT
OTHER

(Specify)

ACTIVE

COORDINATING ACTIVITIES

FULL WEIGHT BEARING

WHEELCHAIR INDEPENDENT

STRETCHING

ACTIVE ASSISTIVE

NON-WEIGHT BEARING

PROGRESS BED TO WHEELCHAIR

COMPLETE AMBULATION

PASSIVE ROM

PROGRESSIVE RESISTIVE

PARTIAL WEIGHT BEARING

RECOVERY TO FUL FUNCTION

TREATMENT GOALS:

ADDITIONAL THERAPIES
O.T.

SIGNATURE OF AND TITLE OF THERAPIST

SPEECH

DATE

DIETARY
SOCIAL WORK ASSESSMENT (To be completed by Social Worker)

PRIOR LIVING ARRANGEMENTS

LONG RANGE PLAN

ADJUSTMENT TO ILLNESS OR DISABILITY

SIGNATURE OF SOCIAL WORKER

DATE RECEIVED BY VA

VA AUTHORIZATION FOR PAYMENT

ELIGIBILITY FOR PER DIEM PAYMENT
APPROVED

DISAPPROVED

APPROVED FOR 70% SERVICE CONNECTED DISABILITY

YES

NO

SIGNATURE OF VA OFFICIAL
VA FORM
APR 2009

10-10SH

DATE

DATE

LEVEL OF CARE RECOMMENDED
NHC

DOMICILIARY

HOSPITAL

ADHC

APPROVED FOR ADMITANCE BECAUSE OF SERVICE CONNECTED ILLNESS ( IF LESS THAN 70%)
ILLNESS:
SIGNATURE OF VA PHYSICIAN

DATE

PAGE 2

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICE
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are
not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time
expended by all individuals who must complete this form will average 30 minutes. This includes the time it will take to read
instructions, gather the necessary facts and fill out the form. The information requested on this form is solicited under the
authority of Title 38, U.S.C., Sections 1741, 1742 and 1743. It is being collected to enable us to determine your eligibility for
medical benefits in the State Home Program and will be used for that purpose. The income and eligibility you supply may be
verified through a computer matching program at any time and information may be disclosed outside the VA as permitted by
law; possible disclosures include those described in the "routine uses" identified in the VA system of records 24VA136,
Patient Medical Record-VA, published in the Federal Register in accordance with the Privacy Act of 1974. Disclosure is
voluntary; however, the information is required in order for us to determine your eligibility for the medical benefit for which
you have applied. Failure to furnish the information will have no adverse affect on any other benefits to which you may be
entitled. Disclosure of Social Security number(s) of those for whom benefits are claimed is requested under the authority of
Title 38, U.S.C., and is voluntary. Social Security numbers will be used in the administration of veterans benefits, in the
identification of veterans or persons claiming or receiving VA benefits and their records and may be used for other purposes
where authorized by Title 38, U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where required by other statute.
VA FORM
APR 2009

10-10SH