Oklahoma Developmental Disabilities Services sends this five-page referral with a service recipient to each health care appointment. Provider staff describe current medications, allergies, symptoms and recent illness or admissions; the clinician then records diagnosis or test results, recommendations, treatments, medication changes, monitoring instructions for staff and tardive dyskinesia monitoring.
The health care provider seen at the appointment completes the Healthcare Provider/Medical Facility Section (pages 3 to 5) and signs. DDS provider staff complete the client and health information sections beforehand and sign as the person completing the form.
Download the current version from the source each time; forms change without notice.
Referral Form for Treatment or Examination
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The Healthcare Provider/Medical Facility Section: diagnosis or diagnostic test results, recommendations including preventive screenings, treatments, medication changes with reasons, monitoring instructions for staff, tardive dyskinesia monitoring and the next appointment, followed by the provider's printed name, signature and date.
The form asks whether the service recipient is prescribed a medication associated with a risk of tardive dyskinesia, including metoclopramide. If so, the provider names the medication and gives the last TD assessment date and score, with a copy of the current assessment for the recipient's records.
The routing section says that within one business day one copy goes to the health care provider, one to the home record and one to the DDS case manager. The index lists it as DDS-5 Referral Form for Examination or Treatment.