| ENTRY SPECIFICATION |
{"name": "MAHC-10",
{"id": "q9557", "type": "ChoiceQuestion", "required": true, "inline": false,
"columns": 1,
"choices":[
{"id": "c6173", "text": "0. No", "quickKey": 0},
{"id": "c6174", "text": "1. Yes", "quickKey": 1}
]},
{"id": "q9565", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "9. Pain affecting level of function<br /> Pain often affects an individual's
desire or ability to move or pain can be a factor in depression or compliance
with safety recommendations.",
"intro": "Required Core Elements<br /> Information may be gathered from medical record,
"text": "1. Age 65+",
assessment and if applicable, the patient/caregiver. <br /> Beyond protocols
listed below, scoring should be based on your clinical judgment.",
"columns": 1,
"choices":[
{"id": "c6173", "text": "0. No", "quickKey": 0},
{"id": "c6174", "text": "1. Yes", "quickKey": 1}
]},
{"id": "q9566", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "10. Cognitive impairment<br /> Could include patients with dementia, Alzheimer's
or stroke patients or patients who are confused, use poor judgment, have
"intro": "Required Core Elements<br /> Information may be gathered from medical record,
decreased comprehension, impulsivity, memory deficits. Consider patients ability
to adhere to the plan of care.",
"intro": "Required Core Elements<br /> Information may be gathered from medical record,
assessment and if applicable, the patient/caregiver. <br /> Beyond protocols
listed below, scoring should be based on your clinical judgment.",
"columns": 1,
"choices":[
{"id": "c6173", "text": "0. No", "quickKey": 0},
{"id": "c6174", "text": "1. Yes", "quickKey": 1}
]}]
assessment and if applicable, the patient/caregiver. <br /> Beyond protocols
}
listed below, scoring should be based on your clinical judgment.",
"columns": 1,
"choices":[
{"id": "c6173", "text": "0. No", "quickKey": 0},
{"id": "c6174", "text": "1. Yes", "quickKey": 1}
]},
"restartDays": 2,
{"id": "q9558", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "2. Diagnosis (3 or more co-existing)<br /> Includes only documented medical
diagnoses",
"intro": "Required Core Elements<br /> Information may be gathered from medical record,
assessment and if applicable, the patient/caregiver. <br /> Beyond protocols
listed below, scoring should be based on your clinical judgment.",
"columns": 1,
"choices":[
{"id": "c6173", "text": "0. No", "quickKey": 0},
{"id": "c6174", "text": "1. Yes", "quickKey": 1}
"printTitle": "Missouri Alliance for Home Care - 10 questions",
]},
{"id": "q9559", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "3. Prior history of falls within 3 months<br /> Any unintentional change in
position resulting in coming to rest on the ground or at a lower level",
"intro": "Required Core Elements<br /> Information may be gathered from medical record,
assessment and if applicable, the patient/caregiver. <br /> Beyond protocols
listed below, scoring should be based on your clinical judgment.",
"columns": 1,
"choices":[
{"id": "c6173", "text": "0. No", "quickKey": 0},
"content":[
{"id": "c6174", "text": "1. Yes", "quickKey": 1}
]},
{"id": "q9560", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "4. Incontinence<br /> Inability to make it to the bathroom or commode in timely
manner<br /> Includes frequency, urgency, and/or nocturia.",
"intro": "Required Core Elements<br /> Information may be gathered from medical record,
assessment and if applicable, the patient/caregiver. <br /> Beyond protocols
listed below, scoring should be based on your clinical judgment.",
"columns": 1,
"choices":[
{"id": "i2616", "type": "IntroText",
{"id": "c6173", "text": "0. No", "quickKey": 0},
{"id": "c6174", "text": "1. Yes", "quickKey": 1}
]},
{"id": "q9561", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "5. Visual Impairment<br /> Includes but not limited to, macular degeneration,
diabetic retinopathies, visual field loss, age related changes, decline in
visual acuity, accommodation, glare tolerance, depth perception, and night
vision or not wearing prescribed glasses or having the correct prescription.",
"intro": "Required Core Elements<br /> Information may be gathered from medical record,
assessment and if applicable, the patient/caregiver. <br /> Beyond protocols
"text": "Required Core Elements<br /> Information may be gathered from medical record,
listed below, scoring should be based on your clinical judgment.",
"columns": 1,
"choices":[
{"id": "c6173", "text": "0. No", "quickKey": 0},
{"id": "c6174", "text": "1. Yes", "quickKey": 1}
]},
{"id": "q9562", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "6. Impaired functional mobility<br /> May include patients who need help with
IADLS or ADLS or have gait or transfer problems, arthritis, pain, fear of
falling, foot problems, impaired sensation, impaired coordination or improper
assessment and if applicable, the patient/caregiver. <br /> Beyond protocols
use of assistive devices.",
"intro": "Required Core Elements<br /> Information may be gathered from medical record,
assessment and if applicable, the patient/caregiver. <br /> Beyond protocols
listed below, scoring should be based on your clinical judgment.",
"columns": 1,
"choices":[
{"id": "c6173", "text": "0. No", "quickKey": 0},
{"id": "c6174", "text": "1. Yes", "quickKey": 1}
]},
{"id": "q9563", "type": "ChoiceQuestion", "required": true, "inline": false,
listed below, scoring should be based on your clinical judgment."
"text": "7. Environmental hazards<br /> May include but not limited to, poor illumination,
equipment tubing, inappropriate footwear, pets, hard to reach items, floor
surfaces that are uneven or cluttered, or outdoor entry and exits.",
"intro": "Required Core Elements<br /> Information may be gathered from medical record,
assessment and if applicable, the patient/caregiver. <br /> Beyond protocols
listed below, scoring should be based on your clinical judgment.",
"columns": 1,
"choices":[
{"id": "c6173", "text": "0. No", "quickKey": 0},
{"id": "c6174", "text": "1. Yes", "quickKey": 1}
},
]},
{"id": "q9564", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "8. Poly Pharmacy (4 or more prescriptions - any type)<br /> All PRESCRIPTIONS
including prescriptions for OTC meds. Drugs highly associated with fall risk
include but not limited to, sedatives, anti-depressants, tranquilizers,
narcotics, antihypertensives, cardiac meds, corticosteroids, anti-anxiety drugs,
anticholinergic drugs, and hypoglycemic drugs. ",
"intro": "Required Core Elements<br /> Information may be gathered from medical record,
assessment and if applicable, the patient/caregiver. <br /> Beyond protocols
listed below, scoring should be based on your clinical judgment.",
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