Attachment 5 - PBNDS Intake Screening Form.pdf

INTAKE SCREENING

Identification

Patient was identified by (check 2 sources): Wrist Band Picture Verbally ID Badge Other:

Chaperone Present? Yes No If yes, give chaperone name:

Date of arrival at facility: Time of arrival: Time of initial screening:

If transferred from another facility, did medical transfer summary accompany the patient? Yes No Not Applicable Was the Pre-Screening Note reviewed? Yes No

Subjective Communication Assessment:

What language do you speak? English Spanish Other:

Interpreter provided? Yes No If yes, name or INT number:

If No, patient speaks: English fluently Provider fluent in patient’s native language No interpreter available at this time

Do you have any difficulty with: Hearing Speech Vision Check if yes. If yes, what accommodation do you need to help you read, communicate, or navigate the facility?

Disability Screening:

Do you have any difficulty with walking, standing, or climbing stairs? Yes No If yes, explain:

Do you have any difficulty reading or writing? Yes No If yes, explain:

What was the highest grade completed in school?

Do you have any difficulty understanding directions? Yes No If yes, explain:

Medical Screening:

How do you feel today? (Explain in his/her own words)

Are you currently having any pain? Yes No If yes, complete pain assessment below

a. Character of pain: b. Location: c. Duration: d. Intensity: (0-10 pain scale)

e. What relieves pain or makes it worse?

Do you have any current or past medical problems? Yes No If yes, explain:

Last Name: First Name:

A#: Country of Origin:

Date of Arrival: DOB:

Facility: Sex:

Medical Screening (continued)

Are you currently or in the past year have you taken any medication on a regular basis, including over the counter and herbal? Yes If yes, list medications:

No

Do you have your medications with you? Yes No If yes, list medications and disposition:

Do you have any allergies to medication or food? Yes No If yes, list all:

Are you now or have you ever been treated by a doctor for a medical condition to include hospitalizations, surgeries, infectious or communicable diseases? Yes No If yes, explain:

Do you now or have you ever had Tuberculosis (TB)? Yes No

In the past 2 months, have you experienced any of the following signs or symptoms continuously for more than 2 weeks:

Cough? Yes No Coughing up blood? Yes No Chest pain? Yes No Loss of appetite? Yes No

Fever, chills, or night sweats for no known reason? Yes No Unexplained weight loss? Yes No

Symptom screening with positive responses(s) is concerning for active TB: Yes No If yes, explain:

Referred to provider for further evaluation. Yes No

Have you had any recent sudden changes with your vision or hearing? Yes No If yes, explain:

Do you have any specific dietary needs? Yes No If yes, explain:

Have you traveled outside of the US within the past 30 days? Yes No If so, where?

Have you ever had or have you ever been vaccinated against Chicken Pox? Yes No Admits prior infection

LGBT Screening

Are you gay, lesbian, bisexual, transgender, intersex or gender non-conforming? Yes No

If transgender, what is your gender self-identification?

Last Name: First Name:

A#: Country of Origin:

Female Patient Only

Are you pregnant? Yes No Not Applicable If yes, date of last menstrual period:

Are you currently breastfeeding? Yes No If yes, when is the last day you breastfed?

Have you had unprotected sexual intercourse in the past 5 days? Yes No If yes, would you like to speak to a medical provider about emergency contraception to prevent a possible pregnancy?

If yes, contact a medical provider immediately for guidance.

Yes No

Oral Screening

Are you having any significant dental problems? Yes No If yes, explain:

Do you have dentures, partials, braces, etc? Yes No If yes, do you have these items with you?

Mental Health Screening

Have you ever been diagnosed with mental illnesses or mental health conditions? Yes No If yes, what illness?

Have you ever received counseling, medication or hospitalization for mental health problems (to include outpatient treatment)?

Yes No If yes, explain.

Refer for follow-up and appropriate treatment as necessary.

Do you have a history of self-injurious behavior? Yes No If yes: Cutting Self-mutilation Other

Most recent If yes, refer for follow-up and appropriate treatment as necessary.

Have you ever tried to kill or harm yourself? Yes No If yes, when did the attempt occur?

Method: Gun Hanging Cutting skin Pills Other If attempt was within the last 90 days, make referral to mental health immediately.

Are you currently thinking about killing or harming yourself? Yes No If yes, make referral to mental health immediately.

Do you have a history of assaulting or attacking others? Yes No

Do you know of someone in this facility whom you wish to attack or harm? Yes No

If yes, who is this person? If yes, make referral to mental health immediately.

Do you now or have you ever heard voices that other people don't hear, seen things or people that others don't see, or felt others were trying to harm you for no logical or apparent reason? Yes No If yes, explain:

Last Name: First Name:

A#: Country of Origin:

Sexual Abuse and Assault Screening

Have you been a victim of physical or sexual abuse or assault? Yes No If yes, explain:

If yes, refer for medical or mental health evaluation as appropriate.

Do you feel that you are in danger of being physically or sexually assaulted while you are in custody?

If yes, refer for follow-up and appropriate treatment as necessary.

Yes No If yes, explain:

Have you ever sexually assaulted or abused another person? Yes No If yes, explain:

If yes, refer for medical or mental health evaluation as appropriate.

Trauma History Screening

Have you had a physical or emotional trauma due to abuse or victimization? Yes No

Have you ever experienced, witnessed or been confronted with an event that involved actual or threatened death or serious injury (can include domestic violence, sexual assault, robbery, natural disaster, war, serious illness, terrorism). Yes No If yes, answer the following:

• Was your response to this event intense fear, helplessness or horror? Moderate Extreme

• Has this experience caused significant distress or impairment in your life? Moderate Extreme

• Has it affected your interpersonal relationships, work or other areas? Moderate Extreme

• Is this experience currently causing significant distress or impairment in your life? Moderate Extreme

If the patient experienced any of the above, refer for follow-up and appropriate treatment as necessary.

Cultural/Religious Assessment

Is there anything important to know about your religious or cultural beliefs that are of concern to you while in detention?

If yes, explain:

Yes No

Substance Use/Abuse Screening

Have you ever been treated for drug and/or alcohol problems? Yes No

Have you ever suffered withdrawal symptoms from drug and/or alcohol use? Yes No

Are you able to stop using drugs or alcohol if you want? Yes No

Have you ever blacked out or experienced memory loss from drinking or drug use? Yes No

Have drug or alcohol use negatively impacted your life (family, work, relationships, criminal charges)? Yes No

If yes to any of the above questions, explain:

Refer for follow-up and appropriate treatment as necessary.

Last Name: First Name:

A#: Country of Origin:

Substance Use/Abuse Screening (continued)

In the past three months, have you used tobacco, alcohol, illegal drugs, or misused prescription drugs? Yes No

If yes, complete the following (refer for follow-up and appropriate treatment as necessary).

Substance Used/Route of Use Date of Last Use Amount/Quantity Last Used

Objective Patient does not appear to have abnormal physical, mental, and/or emotional characteristics. Yes No

Patient does not appear to have barriers to communication. Yes No

Patient is oriented to: Person Yes No Place Yes No Time Yes No

If you observe any of the following, check the appropriate box and document findings below:

Appearance: Sweating Shaking/tremors Anxious Disheveled Ill appearance

Findings:

Behavior: Disorderly Appropriate Insensible Agitation Inability to focus/concentrate Findings:

State of Consciousness: Alert Responsive Lethargic Findings:

Ease of Movement: Body deformities Gait Findings:

Breathing: Persistent cough Hyperventilation Findings:

Skin: Lesions Jaundice Rashes Infestations Nits (lice) Bruises Scars Tattoos Needle Marks or Indications of Drug Use Findings:

Developmental or Physical Disabilities: Developmental Delay Para/quadriplegia Stroke Amputation Cardiac condition Findings:

Assistive Devices: Glasses/Contacts Hearing aid(s) Denture(s)/Partial(s) Orthopedic brace Prosthetic Cane Findings:

None Observed

Comments/Other Findings:

Vital Signs T P Resp BP HT WT HCG Results: Pos Neg N/A

Last Name: First Name:

A#: Country of Origin:

Assessment Initial Medical Screening:

No findings requiring referral

Findings requiring referral identified. See disposition below.

List all findings:

Plan Disposition:

General population

General population with referral for: Medical Mental health care

Isolation until medically evaluated

Referral for immediate: Medical Mental health Dental care

Details of referral:

Care/Intervention/Follow-up:

Physical examination/Health Assessment will be performed within 14 days.

Physical exam will be scheduled for patient.

Tuberculin Skin Test (TST) administered Left forearm Right forearm

Chest X-Ray (CXR) completed with appropriate shielding

TST or CXR not needed. Transfer Summary accompanying patient documents negative screening within timeframe allowed by policy.

The following care/treatment was provided during this Intake Screening.

Last Name: First Name:

A#: Country of Origin:

Patient Education:

Tuberculosis screening and need for tuberculin skin test (TST) or chest x-ray (CXR) explained to patient prior to performance.

Access to medical, dental, and mental health care explained to patient as well as grievance process.

Given the Dealing with Stress brochure in language.

Given the Medical Orientation brochure in language.

Given the Health Information brochures in language.

Patient verbalized understanding of teaching or instruction provided.

Patient was asked if he or she had any additional questions and all questions were addressed.

Female ONLY: Educated and provided brochure describing female medical and mental health services related to pregnancy, terminated/miscarried pregnancies, contraception, family planning and age-appropriate gynecological health care.

Other education provided:

Provider's Signature Stamp / Printed Name Date Time

Reviewer's Signature Stamp / Printed Name Date Time

Last Name: First Name:

A#: Country of Origin: