Form NDP14 "Health Care Practitioner (Hcp) Consultation Form" - Alabama

What Is Form NDP14?

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 1, 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 NDP14 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 NDP14 "Health Care Practitioner (Hcp) Consultation Form" - Alabama

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NDP 14
July 2018
HEALTH CARE PRACTITIONER (HCP) CONSULTATION FORM
COMPLETE PRIOR TO APPOINTMENT(Do not leave blank spaces)
Today’s Date:
Time:
HCP’s Name:
(credentials)
Appt Date:
Appt Time:
Reason for Visit:
PERSON’S INFORMATION
Person’s Name
DOB:
Sex:
Diet:
Address:
Ph# (
)
Allergies:
Current Dx(s):
Other HCP(s):
MAS Nurse Name:
RN/LPN
Contact #
(
)
COPY of MAR ATTACHED?
: □ YES
□ NO
(Check One)
Signature of Person Completing Form:
Date:
TO BE COMPLETED BY HCP AND RETURNED WITH PERSON
□ New/Changed Diagnosis: ________________________________________________
□ Follow-up/Next Appointment Date/Time: ___________________________________
CURRENT FINDINGS:
(Attach Prescriptions to This Form)
________________________________
ORDERS:
________________________________________________________________________
HCP Signature _________________________________
Date ______________
(Credentials)
1
NDP 14
July 2018
HEALTH CARE PRACTITIONER (HCP) CONSULTATION FORM
COMPLETE PRIOR TO APPOINTMENT(Do not leave blank spaces)
Today’s Date:
Time:
HCP’s Name:
(credentials)
Appt Date:
Appt Time:
Reason for Visit:
PERSON’S INFORMATION
Person’s Name
DOB:
Sex:
Diet:
Address:
Ph# (
)
Allergies:
Current Dx(s):
Other HCP(s):
MAS Nurse Name:
RN/LPN
Contact #
(
)
COPY of MAR ATTACHED?
: □ YES
□ NO
(Check One)
Signature of Person Completing Form:
Date:
TO BE COMPLETED BY HCP AND RETURNED WITH PERSON
□ New/Changed Diagnosis: ________________________________________________
□ Follow-up/Next Appointment Date/Time: ___________________________________
CURRENT FINDINGS:
(Attach Prescriptions to This Form)
________________________________
ORDERS:
________________________________________________________________________
HCP Signature _________________________________
Date ______________
(Credentials)
1
NDP 14
July 2018
TO BE COMPLETED BY MAS NURSE
DATE _________________
TIME _______________ AM/PM
Assessment
T _____ P _____ R _____ BP _____
S
(What you see, hear, feel, smell, etc.?)
O
(What client says)
A
(Problem)
P
(Changes to Plan of Care?)
Intervention
Y
N
N/A
COMMENTS/NOTES
Follow-up for new
problem/ diagnosis?
New orders
received?
a. Transcribed to
MAR?
b. Communicated to
MAC Worker(s)
c. Communicated to
Day Program?
d. Guardian/Family
notified?
Medications
Ordered?
a. Available at the
agency?
Referrals?
(Arranged? Date? Time? Place?)
a. Lab
b. X-ray
c. Procedure
d. Consult
(explain)
MAS Nurse Signature __________________________________ Date ______________
2
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