Provider’s Admission Exam
Health History-currently charted
Physical Exam- currently charted
Immunizations: I have sent for access to chirp/IN access to be able to upload current
immunizations records to chart. (I will make sure this is completed on admit and followup if there are any issues.)
Dental Exam: This is only for clients who have not had a dental exam in 6 months. I
have already reached out to Gosport Dental to see if they will be able to facilitate this. It
is required that have a dental exam with 30 days if one is not on file for client. If we can
please get dentist name/ last date they were seen. DCS requires to have this
documentation on file.
Vision and Hearing Screening- Vision screening will be completed by nursing staff
upon admission. I have asked for clarification and am waiting a response.
Written statement of medical finding should include
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Physical defects
Need for Dental Care
State of Development
Ability/Limitation for programing/groups/activities.
o Example: Based on my medical assessment client has no
limitations to ability to participate in facility programing, groups,
activities.