1 SNBC INSTITUTIONAL CARE COORDINATION DOCUMENT (ICCD) *Fields with asterisks are required for MMIS entry *Client Last Name: *Client First Name: *M.I.: *Birth Date: *PMI Number UCare ID Number: Address: Phone number: Facility: Primary Spoken Language: *Referral Date *LTCC CTY: UCM *Activity Type Date (date of assessment) *Activity Type *COS *COR *CFR *Legal Rep Status – Adult (age 18 or older) Legal Rep Name: Legal Rep Contact Info: *Primary Diagnosis Name: *Dx Code: *Secondary Diagnosis Name: *Dx Code: *Is there a history of a DD Dx? ☐Y ☐N If so, what is the dx? *Is there a history of a MI Dx? ☐Y ☐N If so, what is the dx? *Is there a history of a BI Dx? ☐Y ☐N If so, what is the dx?
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SNBC INSTITUTIONAL CARE COORDINATION DOCUMENT (ICCD) · 2018-10-08 · 1 SNBC INSTITUTIONAL CARE COORDINATION DOCUMENT (ICCD) *Fields with asterisks are required for MMIS entry *Client
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*DressingHow well are you able to manage dressing? By dressing, we mean laying out the clothes and putting them on, including shoes, and fastening clothes. Would you say that you:
*GroomingHow well are you able to manage the grooiming activities such as combing your hair, putting on makeup, shaving and brushing your teeth? Would you say that you:
*BathingHow well can you bathe or shower yourself? Bathing or showering by yourself means washing all parts of the body including your hair and face. Would you say that you:
*EatingHow well can you manage eating by yourself? Eating by yourself means drinking, eating and cutting most foods on your own. Would you say that you:
*BedMobilityHow well can you manage sitting up or moving around in bed? Would you say that you:
*TransferringHow well can you get in and out of a bed or chair? Would you say that you:
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*WalkingHow well are you able to walk around, either without any help or with a cane or walker, but not including a wheelchair? (Independence in walking refers to the ability to walk short distances around the house. Independence in walker does not include climbing stairs.) Would you say that you:
*EmotionalHealthHow would you rate your emotional health?
*ToiletingHowe well can you manage using the toilet? Would you say that you:
*SubjectiveEvaluationofHealthOverall, would you rate your physical health as excellent, good, fair, or poor?
How well would you say that you are able to communicate your needs or concerns to providers (for example, in‐home providers, medical providers, mental health providers)?