IMLS Nurses Worksheet
Client Name: ___________________________________ DOB: ____/____/______ Date: ___________
Nurse Name: ____________________________________ Nurse Phone: (___) - _____ - _______
Agency: ________________________________________ Agency Phone: (___) - _____ - _______
Section
Score
1 through 4
Title of Supporting
Documentation
A. Medication Administration
• Do not count: Home Health, Hospice, Dr. Office, Clinic, etc.
• Do not count Tube feeding & respiratory treatments in this
section
B. Medical Care and Supervision
• Hospitalization past year
• Medical Care Contacts past year
o PCP or specialists contacts resulting in change
o ER/Urgent Care visits w no hospitalization
o Diagnostic, Lab, radiological Procedures, swallow
studies, etc.
C. Feeding and Nutrition
• Nutritional Therapy & Fluid Balance
o Oral eaters
o Special Dietary Needs, i.e., I O, wt./measure
foods
• Tube Feeding
D. Respiratory
• Aspiration Risk
• Ventilator/ C-PAP/B-PAP
• Oxygen
• Suctioning
• Respiratory Therapy/Respiratory Hygiene
E. Neurological
• Seizures
• Spasticity
• Implantable Devices
F. Skin Care Assessment & Treatment
• Preventive, Wound and Dressing Management
G. Other Complex Medical Needs
• Diabetes
• Renal/Bladder
• Additional Direct Nursing Needs
Add all Section scores to get Total Score:
Current eCHAT Acuity: Low Moderate High
Long Term IMLS Short Term IMLS (Note: Short Term Stay – up to 90 days)
Submit
to the
Case
Manager
with
supportin
IMLS Nurses Worksheet
State of NM/DDSD
12.21.12 review 9.21.15, 12.27.17, 3.
1.18
IMLS Nurses Worksheet - 01
