CBRF admission assessment and service plan checklist

Wisconsin CBRF | PublicProof Academy working document

Non-editable educational sample of record categories. Not an approved clinical form or treatment protocol. A qualified professional must review suitability before use in their own secure system.

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Before admission

Assessment of needs, abilities, physical and mental condition completed (emergency admission: within 5 days)
Needs fit our class, client group and the 3-hour weekly nursing limit
Evacuation ability assessed (F-62373) and fits our ambulatory designation
Program statement given to resident or legal representative
Resident rights, grievance contacts and house rules given in writing
Admission agreement with rates and extra charges signed
Payer confirmed: private pay, or MCO authorization in hand (never assume)

After admission

Practitioner orders on file for every medication and supplement
Medication regimen review scheduled within 30 days by pharmacist or physician
Individual service plan completed within 30 days with resident, representative and case manager
Service plan review date set (at least annually or on change of condition)

Use rule: Education and organization only. Record the agency, official source, checked date, cost, proof saved and responsible person for every consequential requirement. Unknown means stop and confirm. Example rows are labeled EXAMPLE and are not your data.