Form 3090 "Nursing Health Screening Within 72 Hours of Community Placement" - Texas

What Is Form 3090?

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

Form Details:

  • Released on August 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • 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 fillable version of Form 3090 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form 3090 "Nursing Health Screening Within 72 Hours of Community Placement" - Texas

486 times
Rate (4.4 / 5) 29 votes
Form 3090
August 2020-E
Home and Community Based Services Adult Mental Health (HCBS-AMH)
Nursing Health Screening Within 72 Hours of Community Placement
Name of Program Participant
Date
A. Medical History
Does the individual report any of the following? Check all that apply and describe below.
Allergies
Appetite changes
Autoimmune disorder
Adverse reaction to medications
Cancer
Chronic pain (include location in Comments below)
Diabetes
Enuresis/encopresis
Head injury/stroke
Heart/vascular problems
Hypertension
Kidney disease
Liver disease
Loss of consciousness
Musculoskeletal
Parasites/scabies/lice
Respiratory problems
Reproductive/Pregnancy
Seizures
Sexually transmitted disease
Skin Problems
Sleep disturbances
Thyroid problems
Vision/Hearing
Weight changes
Comments:
B. Medication Administration
Does the individual require assistance from unlicensed personnel to measure pulse, respiration, blood pressure,
Yes
No
temperature, weight, fluid intake or output, oxygen saturation or glucose levels?
Does the individual require assistance from unlicensed personnel to perform sterile procedures (e.g., wound care including
Yes
No
bed sores, tracheostomy care/suctioning, urinary catheter placement and care)?
Does the individual require assistance from unlicensed personnel to use a CPAP, BiPAP or other oxygen therapy?
Yes
No
Does the individual require assistance from unlicensed personnel to use a vagal nerve stimulator for seizure control?
Yes
No
Does the individual require assistance from unlicensed personnel to administer PRN medication to manage behavior?
Yes
No
Does the individual require administration of medication by unlicensed personnel to ensure that medications are received
Yes
No
safely?
Indicate if the individual requires any of the following routes of administration:
Oral
Topical
Nasal
Metered dose inhaler (by mouth)
Eye or ear drops
Injections (including insulin)
Sublingual (under the tongue)
Suppositories (rectal or vaginal)
Intravenous/IV
Nebulizer
Enteral tube/naso-gastric (NG)/gastric (G-tube)
Form 3090
August 2020-E
Home and Community Based Services Adult Mental Health (HCBS-AMH)
Nursing Health Screening Within 72 Hours of Community Placement
Name of Program Participant
Date
A. Medical History
Does the individual report any of the following? Check all that apply and describe below.
Allergies
Appetite changes
Autoimmune disorder
Adverse reaction to medications
Cancer
Chronic pain (include location in Comments below)
Diabetes
Enuresis/encopresis
Head injury/stroke
Heart/vascular problems
Hypertension
Kidney disease
Liver disease
Loss of consciousness
Musculoskeletal
Parasites/scabies/lice
Respiratory problems
Reproductive/Pregnancy
Seizures
Sexually transmitted disease
Skin Problems
Sleep disturbances
Thyroid problems
Vision/Hearing
Weight changes
Comments:
B. Medication Administration
Does the individual require assistance from unlicensed personnel to measure pulse, respiration, blood pressure,
Yes
No
temperature, weight, fluid intake or output, oxygen saturation or glucose levels?
Does the individual require assistance from unlicensed personnel to perform sterile procedures (e.g., wound care including
Yes
No
bed sores, tracheostomy care/suctioning, urinary catheter placement and care)?
Does the individual require assistance from unlicensed personnel to use a CPAP, BiPAP or other oxygen therapy?
Yes
No
Does the individual require assistance from unlicensed personnel to use a vagal nerve stimulator for seizure control?
Yes
No
Does the individual require assistance from unlicensed personnel to administer PRN medication to manage behavior?
Yes
No
Does the individual require administration of medication by unlicensed personnel to ensure that medications are received
Yes
No
safely?
Indicate if the individual requires any of the following routes of administration:
Oral
Topical
Nasal
Metered dose inhaler (by mouth)
Eye or ear drops
Injections (including insulin)
Sublingual (under the tongue)
Suppositories (rectal or vaginal)
Intravenous/IV
Nebulizer
Enteral tube/naso-gastric (NG)/gastric (G-tube)
Form 3090
Page 2 / 08-2020-E
C. Special Procedures
Eating
Does the individual require unlicensed personnel to provide special diets or additives (e.g., thickening agents) for oral
Yes
No
feeding?
Does the individual require unlicensed personnel to intervene due to a history of frequent choking episodes?
Yes
No
Bathing
Does the individual require unlicensed personnel to bathe him/her using specific bathing techniques because the individual
has a chronic condition (e.g., brittle bone disease, history of aspiration or GERD (gastric reflux), etc.) that would put the
individual at significant risk for injury if the unlicensed personnel were not skilled in the specific bathing techniques?
Yes
No
Toileting
Does the individual require unlicensed personnel to perform urinary catheterization, either long term or occasionally?
Yes
No
Does the individual require unlicensed personnel to intervene due to a history of bowel impactions/chronic constipation that
Yes
No
required medical intervention?
Mobility
Does the individual require unlicensed personnel to change his/her position to prevent skin breakdown?
Yes
No
Does the individual require unlicensed personnel to use a mechanical lift to transfer him/her?
Yes
No
D. Signatures
Signature – Individual or Legally Authorized Representative
Date
Signature – Licensed Vocational or Registered Nurse
Title
Date
Signature – Program Provider Representative
Title
Date
Page of 2