COGNITIVE IMPAIRMENT SCREEN Sample Clauses

COGNITIVE IMPAIRMENT SCREEN. Cognitive Functioning: Individual’s current level of alertness, orientation, comprehension, concentration and immediate memory. Response: What is today’s date?  Correct  Incorrect What day of the week is today:  Correct  Incorrect (correct, if within 2 days) How old are you?  Correct  Incorrect When were you born?  Correct  Incorrect Behaviors of Note: (check all that apply):  Wanders Day/Night  Sleep disturbance  Confused  Depressive Feelings  Anxious  Withdrawn/Refuses to Socialize  Agitated (repeated vocalizations, screaming, shouting, moaning, cursing, fidgeting, etc.)  Other: Overall Cognitive Functioning:(check all that apply):  Is alert and oriented, comprehends verbal questions and commands and has accurate recall  Requires prompting and redirection, on occasion, to complete tasks  Has occasional fluctuation in orientation, memory/alertness  Has significant memory loss and is disoriented to person, place and/or time This screen includes indicators, which are often related to cognitive impairment. This is a screen ONLY and is intended to assist the residence in determining if an individual is appropriate for care in an ALR and/or if the individual should be referred to his/her physician for consultation and/or further evaluation or treatment. Comments: New York State Department of Health ASSISTED LIVING RESIDENCE Division of Assisted Living RESIDENT EVALUATION Resident’s Name: _ Facility Name: _ Date of Evaluation: _