What forms are required?

Any individual who receives services from us and has an Individual Service Plan (ISP) should have a completed Health Record (HC-5). This should be entered electronically into Department's HCSIS system, usually by the residential provider agency staff or by the person's service coordinator (or delegated area office staff). A paper copy should be kept with the individual's personal records at their home.

For people who receive residential supports, two other forms are required:

The Annual Health Screening Recommendations (HC-1) is required for the annual physical exam.

The Health Review Checklist (HC-2) is required for all visits with the Primary Health Care Provider including the annual exam.

Why do we have to complete the Health Review Checklist (HC-2) if the individual is just going for a brief follow-up visit with their Primary Care Provider?

The Health Review Checklist was created to relay any possible information relative to an individual's health status to the Health Care Provider whether or not the information appears to be related to the reason for the visit. Early detection and reporting of health conditions that may first be noted as behaviors or changes in activities of daily living can prevent worsening of the condition and may even cause a reversal of the health issue due to early treatment or intervention . It is not expected that direct care staff would be able to determine what information needs to be shared with the HCP. The Health Review Checklist aims to catch early signs and symptoms of an underlying health problem could otherwise go unreported.

Should the Annual Health Screening Recommendations (HC-1) and the Health Review Checklist (HC-2) be used for the ISP?

These forms are not required for the ISP but many providers and families have found it helpful to review the checklists in preparation for a discussion of health planning needs and priorities at the ISP.

How can families use these forms?

While the forms are not required for use by families they may find them helpful when preparing for an annual physical exam or an episodic visit to the Primary Care Provider or even some specialists. The Annual Health Screening Recommendations (HC-1) and the Health Review Checklist (HC-2) may be especially helpful in assisting individuals and families to organize their thoughts and questions for the visit. Individuals who receive minimal supports could also be assisted in preparing these documents prior to a visit in order to more effectively communicate their needs and concerns to the Health Care Provider.

Will the forms be required for individuals leaving nursing homes?

No. However, if any of the forms would be useful, planning teams should feel free to use them.

Are Day Programs required to use these forms?

No. The forms are meant to be used by the entity, usually a residential provider that is responsible for overseeing health care for the individual. However, the Day Programs are encouraged to use any of the tools that they think would be helpful to them in communicating to the residential program or Primary Care Provider what they observe in relation to health issues or needs of individuals in their programs.




This information is provided by the Department of Developmental Services.