CHARLOTTE TGA
CLIENT REASSESSMENT FORM
This form is to be completed VHPLannually or in the event of an unanticipated event(s) or changes in client status. This
form is used as a guide to assist case managers in properly documenting and updating client’s file for reassessment.
Standard: Clients will be re-evaluated through an assessment process which determines the client’s current case
management status and the need for revisions in the care plan.
Date: __________________
Indicate: _____ %LAnnual Reassessment
Case Manager: ___________________________________
_____ Unanticipated event
_____ Change in client status
1. Are there any areas on the original assessment that need to be updated? If so, identify those areas and complete
the documentation. Include updated client data.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
2. Are there any changes, progress, mutually agreed upon goals IRU the care plan? Identify and document changes in
goals, progress, activities, etc.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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Medication and HIV Education Review
Client ID #: ______________________
Category
MCM Signature/Date (required at 6 month review): _______________________________________________
Focus Item
Timeframe
Has your phone number or address changed?
Has your household or living arrangements changed?
Has your primary care provider changed?
Has your Infectious Disease provider changed?
Has your insurance (Private/Medicare/Medicaid) changed?
Has your income changed in the past 3 months?
Have you provided recent income verification to your Medical Case Manager?
MCM use: Medical Encounter form updated and completed today?
MCM use: Patient Clinical Summary printed, attached to this review?
Medication & Purpose
Prescribed by
Where Obtained (ADAP, local
pharmacy, PA, mail order, etc)
Medications
Contact & Clinic
Information
Start
Date
__/__/__
PHS Guidelines
HIV
Knowledge
Screening
Copay Assessment * Clinic and Specialty Care* (write in amount)
CD4 Count and Viral Load assessment (numbers written). If CD4 Count <200, labs
every 2 - 3 months; if CD4 Count >500, labs every 6 months. Viral Load target is ≤48.
What is importance of going to doctor regularly?
What do you know about avoiding HIV transmission to others?
What do you know about avoiding re-infection of HIV?
MCM use: Describe Client’s overall understanding of HIV
PPD yearly if no prior positive test?
Flu vaccine yearly?
Counseling for treatment adherence if on ARV’s?
Annual physical (includes breast, pelvic exam for women, even if hysterectomy)
Colonoscopy if 50+? (CC pays only if rectal bleeding or other problems)
PAP smear yearly for women?
Mammogram every 2 years for women 40+, yearly for women 50+?
PSA for men 50+? (blood test for prostate cancer)
MCM use: Action Plan reviewed today?
3-Month
Review
__/__/__
6-Month
Review
__/__/__
Medication allergies:
Pharmacy usually used, phone:
Category Comments
9-Month
Review
__/__/__
*please obtain verification or
documentation if changes occur*