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INDIANA PASARR PROGRAM DEMENTIA ASSESSMENT CHECKLIST
State Form 47182 (R / 2-99) / BAIS 0029

This form shall become a CONFIDENTIAL RECORD upon completion in accordance with 42 CFR 483.100 et. al.
Name of applicant / resident Social Security number *

* This State agency is requesting disclosure of your Social Security number, under 42 CFR 483.100 et. al. Disclosure is voluntary, and you will not be penalized for refusal.

Date of birth

Name of nursing facility

T elephone number

Address (number and street, city, state, ZIP code)

DEMENTIA ASSESSMENT CHECKLIST Federal PASARR regulations require documentation of a diagnosis of dementia (including Alzheimers Disease and related disorders) if an individual is excluded from PASARR / MI Level II assessment based on the dementia exclusion. An individual with a primary / principal diagnosis of a major mental illness (MI) or who is developmentally disabled (MR/DD) may not be excluded from Level II. T document the dementia diagnosis, the sections of this form may be o completed or other documents which address the criteria in Sections 1-5 may be obtained. This documentation must be retained on the individual's active record in the NF. The purpose is to minimize the risk of overlooking potentially reversible conditions that may be causing or mimicking dementia. If this form is used, ALL sections must be completed. At a minimum, the physician must sign and date the form. If sections are completed by different persons, the person completing it must also sign and date that part. Information must be current in that the patient's condition has not changed since testing results were obtained. Information may be obtained from the phyisican's current records, hospital summaries, etc. NOTE: The nursing facility is responsible to maintain on file acceptable documentation of dementia for any person for whom the exclusion is claimed.

1. DSM Criteria: For dementia, all areas must be checked "Yes". Yes No A. Evidence of short-term and long-term memory loss. (see part 2 below) B. One or more of the following: 1. Impaired abstract thinking; 2. Impaired judgement; 3. Other higher cortical dysfunction (e.g. aphasia, apraxia, agnosia, constructional dyspraxia). Yes Yes Yes Yes No No No No C. A & B significantly interferes with work or usual activity. D. Not occurring exclusively during the course of delirium. E. Insidious onset with generally progressive deterioriating course. F Exclusion of other specfic causes of dementia by history, . physical and laboratory tests. (See parts 3-4 below).

Yes Yes Yes

No No No

2. Mental Status Examination: At least one must be checked. Enter results and interpretation. Attach an additional page if needed. Short Portable Mental Status Questionnaire (SPMSQ) Folstein Mini Mental Status Exam Halstead-Reitan, Luria Nebraska or other neuropsychological assessment battery CAMCOG-Cambridge Cognitive Examination portion of CAMDEX Kahn-Goldfarb MSQ; Face-Hand T est Score: _________________ errors Score: MSQ ____________ errors FHT _____________ errors CBRS-Cognitive Behavior Rating Scale Mattis Dementia Rating Scale Blessed Dementia Scale Wechsler T ests (WAIS-R or WMS-R) Score: _________________ Score: _________________ Score: _________________ Scores: _________________ ___________ Other: Interpretation(s): ___________ / Score: _________________ errors / Score: _________________ errors

Score: _________________

T esting by: (If Mental Status Exam done by someone other than the physician)

Date (month, day, year)

Affiliation:

Credentials

(Continued on the reverse side)

DEMENTIA ASSESSMENT CHECKLIST (Continued) 3. MEDICAL PROCEDURES: Screening and laboratory procedures performed to either substantiate dementia or to rule out other possible causes of dementia. (Check all that have been completed and reviewed.) Medication Review to rule out medication effects Vision / hearing problems Environmental change Assessment for depression and other psychiatric disorders Brain trauma / concussion ASHD / CHF / Alcoholism / Anemia / etc. Thyroid Function Results / interpretation: Urinalysis CBC Electrolyte Panel CT Scan * Screening Metabolic Panel MRI * B12 and Folate Levels EEG * Chest Xray PET * Electrocardiogram Biopsy * Other: _____________________________________________________

* Not required. Record results if completed for purposes other than completion of this form. 4. PATIENT / FAMILY HISTORY: As complete a history as possible should be obtained to supplement the detection of occult medical illness in number 3 above: (NOTE: May be provided by family or other responsible party.)

5. OTHER PROCEDURES used to substantiate diagnosis or to rule out possible causes of dementia: (Indicate "None" if applicable.) Procedure(s): Interpretation:

6. In your best judgment, is the dementia condition expected to be reversible, e.g., dementia following surgery, due to hypothyroidism, etc.? Or is it irreversible and anticipated to worsen? REVERSIBLE IRREVERSIBLE Comments:_______________________________________________________________________________

If reversible, the NF should monitor and assure necessary services are provided for the individual's recovery. 7. Does the person have behavior problems? Is the person a danger to self or others? No

Yes No Yes If Yes to number 7: Explain, including recommended strategies to deal with problems.

Information completed by (If other than the physician):
Name Date (month, day, year)

Affiliation

Credentials

This documentation must be certified by the physician:
Signature of physician Printed name of physician Date (month, day, year)