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Medical Care Code Status Worksheet Revised March 5, 2000 This is a form used by Guardianship Services of Seattle to assist in medical decision making by recording client’s preferences and information by which to assess best interests. GUARDIANSHIP SERVICES OF SEATTLE MEDICAL CARE WORKSHEET INSTRUCTIONS: Purpose is to assist medical decision making by recording client’s preferences and information by which to assess best interests. Complete form during initial contacts with client and others. Update as necessary due to changes in client condition. State basis of notes if other than statements of client. Consult with supervisor at any time care other than full treatment of all illness is considered. Client __________________________________ DOB ___________________ Social Security # ___________________________ Completed by ______________________________ Date _________________ Are there advance directives (living will, health POA, etc)? No/Unknown Yes (attach) Persons in addition to client consulted to obtain information. (e.g. family, close friends, care givers, medical professionals. Identify person and relationship, attach documentation of contacts and statements ) Has the client made statements or implemented decisions in the past that indicate attitudes or beliefs about medical decision making? No/Unknown Yes (attach documentation) Mental condition Ability to participate in decision making Awareness of circumstances People the client is willing to have involved in decision making Living situation Baseline medical status Current medical problems Physical comfort and likelihood of change General satisfaction with circumstances Attitude toward health status Cooperativeness in receiving care Participation in every day activities Attitude toward receiving medical care Toleration for change in health or physical discomfort Toleration of dependence on others Toleration of loss of physical functioning Religious persuasion, other indications of moral beliefs about end of life medical care |