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Littleton Grp Claims Fax: 1-512-328-2017

ResidentVisitorEmployee
(reason for being in location )
ampm

RESIDENT/VISITIOR/EMPLOYEE INFORMATION:

MaleFemale
Private PayMedicareMedicaid
WalkerCaneWheelchair
YesNo
ConfusedNormalDisorientedSedated
Day: (6 am-6 pm)Evening: (6 pm - 12 am)Night: (12 am-6 am)
YesNo
PhysicalFull Bedrail1/2 side railOther
Resident RoomHallwayBathroomDining RmPatioShowerDrivewayActivity RmLiving RoomOther
YesNo
YesNo
Loss of consciousness
YesNo
YesNo
Witnessed FallFound on floorTransferringBehavioral aggressiveAbuse Neglect or ExploitationEquipment MalfunctionElopementMedication ErrorTheftVandalismUnknown
No InjurySurgeryERAdmitted to HospitalD/C to Higher Level of Care
YesNo
YesNo
Cut/laceration / Skin Tear/ AbrasionBruise/ BleedFracture/DislocationBurnSprain / StrainSwellingMedication Related
YesNo
YesNo
YesNo
None NEEDED1st aide @ FacilityERAdmitted HospitalDr. officeOther
(name and relationship to resident)