AHC HRSN SCREENING RESULT

Screened on: [Date]
Person screened: [Name or chart number, age]
Setting: [Clinic, emergency department, inpatient unit, home visit, or telehealth]
Version and mode: [Standard, proxy, or multiuse form; self-completed, completed by a proxy, or read aloud by a screener]
Language: [Language of the form, and any interpreter]
Privacy: [Answered alone, or who was in the room]

CORE DOMAINS
Living situation: [Positive or negative; housing stability and condition of the home]
Food: [Positive or negative; answers to the two food statements]
Transportation: [Positive or negative]
Utilities: [Positive or negative; shut-off threatened or service already off]
Safety total: [4 to 20, with each answer 1 to 5; 11 or more is positive]
Core domains positive: [0 to 5, naming each one]
Not answered: [Questions skipped or declined, and any domain left undetermined]

SUPPLEMENTAL DOMAINS
Asked: [Which of the eight optional domains, or none]
Needs found: [Positive supplemental domains, such as financial strain or loneliness]

SAFETY FOLLOW-UP
Urgency check: [Asked alone: safe to go home today, injuries, strangulation, weapons, children or older adults at risk]
Resources given: [Hotline, advocate, shelter information, and a safe way to reach the person]
Reporting: [State reporting duty considered, and what was done]

HEALTH IMPACT
Effect on care: [How the needs affect conditions, medicines, appointments, or self-management]

REFERRALS AND ACTIONS
Person's priorities: [What they want help with first, in their words]
Declined for now: [Help offered and turned down]
Referrals: [Agency or team, for which need, and consent to share contact details]
Care plan changes: [Medicines, visit format, or follow-up changed because of a need]
Z codes: [Codes recorded for positive domains, from Z55 to Z65]

FOLLOW-UP
Loop closure: [Who checks that each referral worked, and by when]
Next screen: [Date, or within 12 months]

Recorded by: [Name, role]