Attachment B Script. Sample APS Incident Narrative Structure Hotline RFR.pdf

APS Incident Narrative Structure

1) Reporter Information:

• Reporter is a Click or tap here to enter text..

• Reporter is calling in to report Choose an item..

• Alternate phone # to reach reporter when reporter is off shift: Click or tap here to enter text.

• Does reporter have an email address: Choose an item.

• If yes, what is the reporter’s email address: Click or tap here to enter text.

• Does the reporter feel comfortable corresponding with PS agency via email: Choose an item.

• Reporter provided the following additional information regarding themselves:

Click or tap here to enter text.

• The reporter called in regarding multiple elders, and another report is being filed for:

Click or tap here to enter text.

• Under intake ID Click or tap here to enter text.

2) Elder Information:

• Elder is a Click or tap here to enter text.-year old Choose an item. Choose an item. who lives

Click or tap here to enter text..

• The elder speaks Click or tap here to enter text. and Choose an item. require an interpreter.

• Where is the elder currently located at time of intake: Click or tap here to enter text.

• Was EMS called: Choose an item.

• Is elder being transported to another location: Choose an item.

• If yes, location: Click or tap here to enter text.

• The elder has the following medical conditions (please include chronic medical conditions such as heart disease, diabetes, HBP or respiratory diseases; and medical events such as cancer and stroke): Click or tap here to enter text.

• Has the elder been diagnosed with or suspected of having any cognitive impairments such as dementia or Alzheimer’s Disease? Choose an item.

• Is the elder immunocompromised or has some health diagnosis that would make exposure to illness or a virus more dangerous? Choose an item.

• The elder currently takes the following medications: Click or tap here to enter text.

• The elder’s PCP is: Click or tap here to enter text.

• The elder’s HCP is: Click or tap here to enter text.

• The elder’s POA is: Click or tap here to enter text.

• The elder’s Caregiver is: Click or tap here to enter text.

• The elder uses the following assistive device(s) to ambulate: Choose an item.

• Does elder currently have in home services, home health aides, VNA: Choose an item.

• Types of services: Click or tap here to enter text.

• Frequency of services: Click or tap here to enter text.

• The elder requires assistance with the following ADL’s: Click or tap here to enter text.

• The reporter gave the following information regarding the elder’s living conditions: Click or tap here to enter text.

3) Safety Related Questions/PSW Safety:

• Are there factors that would make a home visit unsafe for the elder(s) and/or a PS worker?

Choose an item.

• If yes, please identify: Click or tap here to enter text.

• Has the elder or anyone else in the home had or been exposed to any illness or virus that might require the PS worker to restructure their required in person visit and/or conduct a modified interview such as a hybrid model (e.g. brief visit and then phone or video) or a video or telephone interview? Choose an item.

• If yes, please identify: Click or tap here to enter text.

• Would you be aware of any of the following risk examples that may be present in the home:

• Pets/Animals in the home? Choose an item.

• Any indication of rodents, bugs, pests, or other non-domestic animals in the home? Choose an item.

• Firearms in the home or other weapons? Choose an item.

• Concerns with any structural conditions of the home? Choose an item.

• If yes, please identify: Click or tap here to enter text.

• Is home hoarded? Choose an item.

• Any fire safety issues in the home? Choose an item.

• If yes, please identify: Click or tap here to enter text.

• Any other environmental concerns in the home such as mold or chemicals? Choose an item.

• If yes, is there room to meet safely? Choose an item.

• Elder/Family Aggressive Behavior? Choose an item.

• Elder/Family Mental Health Issues? Choose an item.

• Is there substance abuse in the home by either the elder or another resident? Choose an item.

4) Accessing the Older Adult:

• Are there outdoor areas to meet? Choose an item.

• Is there a window they could speak through? Choose an item.

• Does elder have access to a computer, tablet or a smart phone: Choose an item.

• If yes, which one(s): Click or tap here to enter text.

• Does elder feel safe using the computer, tablet, or smart phone: Choose an item.

• Does elder feel safe having video chats or teleconferences: Choose an item.

• Other Alternative phone #s for the elder: Click or tap here to enter text.

• Does elder have an email address: Choose an item.

• If yes, what is the elder’s email address: Click or tap here to enter text.

• Does elder prefer and feel safe corresponding through email: Choose an item.

5) Incident (If the situation is chronic/ongoing or occurred in the past, please indicate such and ask why the Reporter is calling in their concerns on this particular day):

• The reporter stated the following as their reason for their call:

• The reporter did not know / had limited information regarding:

• The reporter states that the AP Choose an item. have access to the Choose an item.. The elder Choose an item. expected to have financial hardship because of the exploitation.

(Only applicable if the report includes exploitation)