Tier 2 – Provider Entry Form (MEM-PC Protocol)

Patient’s Name: _______________________________________________________________________

Date:

Month Day Year

Informant’s Name: __________________________ Relationship to Patient:___________________

Previously Completed (Tier 1 Visit)?:Annual Medical Wellness Visit Screen: ☐ Yes ☐ No

Mini-Cog: ☐ Yes ☐ NoAD8: ☐ Yes ☐ No

Please check that the patient has brought the following:Medications, bottles, over-the-counter medications. ☐ Yes ☐ No

Advanced Directives (filled out) ☐ Yes ☐ NoInformant ☐ Yes ☐ No

TIER 2 Documentation – Includes (to be filled out after appointment):

To be filled out by informant:

Neuropsychiatric Inventory-Questionnaire ☐ Yes ☐ NoFAQ for Instrumental ADLs ☐ Yes ☐ No

CNS Screen ☐ Yes ☐ No

To be filled out by provider:

MoCA ☐ Yes ☐ NoCategory Fluency ☐ Yes ☐ No

Pentagon Copy ☐ Yes ☐ NoNaming Test ☐ Yes ☐ No

Pentagon Recall ☐ Yes ☐ NoTrails A ☐ Yes ☐ NoTrails B ☐ Yes ☐ No

Circadian Sleep Inventory ☐ Yes ☐ NoAdvanced Directives Prompt ☐ Yes ☐ No

Medication List Review ☐ Yes ☐ No

Tier 2 – Provider Entry Form (MEM-PC Protocol)

2B1

AE

5

D 4 3C

Copy cube

VISUOSPATIAL/EXECUTIVE

[ ] [ ] [ ] [ ] [ ]Contour Numbers Hands

Draw CLOCK (Ten past eleven)(3 points)

[ ] [ ] [ ]

__/5

__/3

POINTS

MEMORY

NAMING

Read list of words, subject must repeat them. Do 2 trials. Do a recall after 5 minutes.

FACE VELVET CHURCH DAISY RED

2nd Trial

1st Trial

ATTENTION Read list of digits (1 digit/sec.). Subject has to repeat them in the forward order [ ] 2 1 8 5 4 Subject has to repeat them in the backward order [ ] 7 4 2 __/2

NoPoints

Read list of letters. The subject must tap his/her hand at each letter A. No points if ≥ 2 errors. [ ] F B A C M N A A J K L B A F A K D E A A A J A M O F A A B __/1

__/3Serial 7 subtraction starting at 100. [ ] 93 [ ] 86 [ ] 79 [ ] 72 [ ] 65

4 or 5 correct subtractions: 3 pts, 2 or 3 correct: 2 pts, 1 correct: 1 pt, 0 correct: 0 pt

LANGUAGE Repeat: I only know that John is the one to help today. [ ] The cat always hid under the couch when dogs were in the room. [ ] __/2

ABSTRACTION Similarity between e.g. banana – orange = fruit. [ ] train – bicycle [ ] watch – ruler

__/5

DELAYED RECALL Has to recall wordsWITH NO CUE

FACE[ ]

VELVET[ ]

CHURCH[ ]

DAISY[ ]

RED[ ]

Points forUNCUEDrecall only

Multiple choice cue

Please rate how sure patient is on a scale: Not (1), Somewhat (2), Pretty (3), Very (4)

ORIENTATION [ ] Date [ ] Month [ ] Year [ ] Day [ ] Place [ ] City __/6

__/30Normal ≥ 26 / 30 TOTALAdd 1 point if ≤ 12 yr edu

__/2

3Tier 2 – Provider Entry Form (MEM-PC Protocol)

4Tier 2 – Provider Entry Form (MEM-PC Protocol)

MocA Letter Fluency:

Letter F “Name as many words that begin with the letter F as you can in one minute” (stop after 1 minute)

LF Total: _______ # Repeats ______

Category Fluency: AFTER Pentagon Copy, BEFORE Pentagon Recall

Animals “Name as many animals as you can in one minute” (stop after 1 minute)

CF Total: _______ # Repeats ______

Pentagon Copy and Recall scoring: 1 point for each distinct 5-sided figure, 1 point for any overlap between two figures, 1 point for 4-sided overlap between two figures.

5-sided figure ____ 5-sided figure ____ Two figure overlap ____ Four-sided figure overlap ____

5Tier 2 – Provider Entry Form (MEM-PC Protocol)

Fold here before copy------present blank side after Category Fluency

6Tier 2 – Provider Entry Form (MEM-PC Protocol)

7Tier 2 – Provider Entry Form (MEM-PC Protocol)

Ask subject to identify the above pictures. Record their response.1. Glove

2. Key

3. Cactus

4. Chair

5. Feather

6. Hammock

# Correct: ________

8Tier 2 – Provider Entry Form (MEM-PC Protocol)

Trail Making Test Parts A & BTrails A: Sample: “On this page are some numbers-begin at #1 (point to numbers as speaking) and draw a line from 1 to 2, 2

to 3, 3 to 4, and so on, until you reach the end. Draw the lines as fast as you can without lifting the pen. Ready? Begin”... [If done correctly go to form A. If unable to correct errors, stop.]

Trails A: “On this page are numbers from 1 to 25-begin at #1 (point to numbers as speaking) and draw a line from 1 to 2, then 2 to 3, and so on, until you reach the end. Work as fast as you can without lifting your pen. Ready—begin”. [Start timing as soon as you finish giving instructions. WATCH FOR ERRORS AND RE-DIRECT IMMEDIATELY IF ANY

ARE MADE. Record time to completion (up to 150 seconds, or if greater than 150 seconds, record the number of completed correct connections = number of connections (max. 24) – # errors).

Trails B (complete only if Trails A is performed in < 150 seconds)Sample: “On this page are some numbers and letters-begin at #1 (point to numbers as speaking) and draw a line

from 1 to A, A to 2, 2 to B, B to 3, 3 to C, and so on, until you reach the end. Draw the lines as fast as you can without lifting the pen. Ready? Begin”. [If done correctly go to form B, otherwise stop.]

Trails B: “On this page are both numbers and letters-begin at #1 (point to numbers while speaking) and draw a line from 1 to A, A to 2, 2 to B, B to 3, 3 to C and so on, until you reach the end. Remember, first you have a number, then a letter, then a number, then a letter, and so on. Work as fast as you can without lifting your pen. Ready—begin”. [Start timing as soon as you finish giving instructions. WATCH FOR ERRORS AND RE-DIRECT IMMEDIATELY IF ANY

ARE MADE. Record time to completion (up to 300 seconds, or if greater than 300 seconds, record the number of completed correct connections = number of connections (max. 24) – # errors).

Trail-Making Test A and B Scoring:

Time Trails A: ______ sec. Percentile: ______

Time Trails B: ______ sec. Percentile: ______

Circadian Sleep Inventory

Part 1. Completed by Subject *** Informant: *** Relationship: ***

9Tier 2 – Provider Entry Form (MEM-PC Protocol)

Part 1 General Sleep Disturbances Frequency Severity F X S

1. Trouble falling asleep at night? *** *** ***

2. Waking up in the middle of the night?* *** *** ***

3. Woken up early and had trouble falling back asleep?*** *** ***

4. Tired or fatigued during the day? *** *** ***

5. Fallen asleep during the day without trying? *** *** ***

6. Slept less at night than normal? *** *** ***

7. Experienced leg cramping or tightening at night? *** *** ***

8. Felt the need to get up and move your legs at night?*** *** ***

9. Experienced breathing difficulties at night?*** *** ***

10. Had unusually vivid or bizarre dreams?*** *** ***

CSI Part 1 Total (FXS) ***Overall Sleep Quality (1-10) ***

Part 2. Is there an informant? (Y/N) ***

If yes, does informant live with Patient/Subject? (Y/N) ***

Does informant sleep in the same room? (Y/N) *** If yes, same bed? (Y/N) ***

Part 2 Circadian Behavioral Disturbances Frequency Severity F X S

11. Arm or leg jerking movements while asleep? *** *** ***

12. Breathing difficulties at night? *** *** ***

13. Wander around at night without purpose? *** *** ***

14. Become combative or violent while asleep? *** *** ***

15. Does he or she appear to be acting out a dream? *** *** ***

16. Does he or she become more agitated at times? *** *** ***

If Yes, check all that apply? (Y/N) 12-8pm *** 8pm-4am *** 4am-12pm ***

CSI Part 2 Total (FXS) ***

11. Does he or she make arm or leg jerking movements while asleep?

12. Does he or she have breathing difficulties at night?

10Tier 2 – Provider Entry Form (MEM-PC Protocol)

13. Does he or she wander around at night without purpose?

14. Does he or she become combative or violent while asleep?

15. Does he or she appear to be acting out a dream?

Advanced Directives Guideline

Second Visit Guidelines

11Tier 2 – Provider Entry Form (MEM-PC Protocol)

Can simply ask the question below, and give handouts, but delay in depth explanation until third (Tier 3) visit

Ask – do you have Advanced Directives? ☐ Yes ☐ No

IF YES:

IF YES, ask them to bring or mail a copy prior to the next visit, can give them a stamped envelope. Explain- “We want to review these and scan them into your medical record so they will be available to all the providers in this healthcare system, if needed”

If NO:

If NO, tell the patient/ family “we will discuss further at the next visit” and give:

1. Advanced directive pamphlet

2. A blank copy of An Advance Directive For North Carolina: A Practical Form for All Adults

Medication List for ReviewList all current medications (OTC & Prescription, as well as how managed).Medications Dosage Date Recommendation

12Tier 2 – Provider Entry Form (MEM-PC Protocol)