Form NDP5 "Client Self-administration Assessment Form" - Alabama

What Is Form NDP5?

This is a legal form that was released by the Alabama Department of Mental Health - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 2, 2018;
  • The latest edition provided by the Alabama Department of Mental Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form NDP5 by clicking the link below or browse more documents and templates provided by the Alabama Department of Mental Health.

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Download Form NDP5 "Client Self-administration Assessment Form" - Alabama

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NDP-5
July 2, 2018
CLIENT SELF-ADMINISTRATION
ASSESSMENT FORM
Location:
Date of
____________________________
Determination:__________________
Consumer’s
Name:_______________________________
Case#:__________________________
Self-Med Administration Criteria
YES
NO
1. The person can effectively verbalized understanding of the purpose for the
medication(s)
2. The person can effectively verbalized common possible side effects,
including:
i.
What to do if dose is missed
ii.
What to do if extra does(s) taken
iii.
What to do if adverse reactions occurs
3. The person can recognize the medication(s)
4. The person can perform return demonstration/correctly verbalize how
and when meds will be self-administered including the appropriate
documentation
The MAS RN/LPN shall make one of the following determinations:
YES
NO
A
CAN self-medicate independently
B
CANNOT self-medicate independently
Can self-medicate with LIMITED assistance
C
(Describe limitations below)
D
Can self-medicate, but REFUSES to do so
Assistance with medications by a MAC Worker is authorized by the MAS Nurse
(Check “Yes” here if MAC Workers will assist with med administration)
SIGNATURE OF MAS RN/LPN MAKING THE DETERMINATION:
MAS RN/LPN NOTES:
NDP-5
July 2, 2018
CLIENT SELF-ADMINISTRATION
ASSESSMENT FORM
Location:
Date of
____________________________
Determination:__________________
Consumer’s
Name:_______________________________
Case#:__________________________
Self-Med Administration Criteria
YES
NO
1. The person can effectively verbalized understanding of the purpose for the
medication(s)
2. The person can effectively verbalized common possible side effects,
including:
i.
What to do if dose is missed
ii.
What to do if extra does(s) taken
iii.
What to do if adverse reactions occurs
3. The person can recognize the medication(s)
4. The person can perform return demonstration/correctly verbalize how
and when meds will be self-administered including the appropriate
documentation
The MAS RN/LPN shall make one of the following determinations:
YES
NO
A
CAN self-medicate independently
B
CANNOT self-medicate independently
Can self-medicate with LIMITED assistance
C
(Describe limitations below)
D
Can self-medicate, but REFUSES to do so
Assistance with medications by a MAC Worker is authorized by the MAS Nurse
(Check “Yes” here if MAC Workers will assist with med administration)
SIGNATURE OF MAS RN/LPN MAKING THE DETERMINATION:
MAS RN/LPN NOTES: