Admission Date: Describe Change of Condition: Date: Time: Circumstances: DO NOT RESUSCITATE ORDER: YES NO CHANGE OF CONDIT...
Signature:  Date: Time: Date:_______________ Time:_______________ Action Taken: Date:_______________ Time:_______________ ...
Examples of a Change of Condition:  (Non-inclusive) <ul><li>Change in Blood Pressure </li></ul><ul><li>Elevated Temperatur...
Admission Date: Dietary Restrictions:  (Diabetic/Mech. Soft, etc.) DO NOT RESUSCITATE ORDER: YES NO ASSSITED LIVING PRE-AD...
Pacemaker Catheter Artificial Limbs Yes No Yes Yes No No Date Date Tuberculin Test (TB) Stools for Occult Blood Breast Exa...
Culture: Religion: Military: Social History:  (Explain) Spoken Language: Community Activities: Enjoys Which Activities: Sl...
Review upon admission for any changes since date of pre-admission assessment.  Initial and Date: Yes No Verbalizes Needs T...
Admission Date: Dietary Restrictions:  (Diabetic/Mech Soft etc.)  DO NOT RESUSCITATE ORDER: YES NO ANNUAL ASSESSMENT Name:...
Catheter Oxygen Tube Feedings Military: Religion: Culture: Medical History:  (Check All That Apply as If There Is a Histor...
Appliances/Aids Used: Yes No Glasses Hearing Aids Upper Dentures Lower Dentures Partial (Dental) Crutches Cane Walker Whee...
Improvement noted in the Following Areas: 1. 2. 3. 4. 5. 6. Decline noted in the Following Areas: 1. 2. 3. 4. 5. 6. Reside...
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Assessment Form

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Transcript of "Assessment Form"

  1. 1. Admission Date: Describe Change of Condition: Date: Time: Circumstances: DO NOT RESUSCITATE ORDER: YES NO CHANGE OF CONDITION ASSESSMENT Name: Last, First, Middle Initial Date of Birth: Age: Sex: M F Facility: Address: Person Completing Assessment: Date: Time: Cause: (Describe) Accident Injury Illness Symptoms Observed Communicable Disease Unknown Notification: Date: Physician Family Legal Representative Case Manager Community Integration Specialist Was there a Significant Change? Yes No Decline in Medical Condition Decline in 1 or More ADL’s Decline in Communication Decline in Cognitive Abilities Decline in Behaviors Decline in Mood Improvement in Medical condition Improvement in 1 or More ADL’s Improvement in Communication Improvement in Cognitive Abilities Improvement in Behaviors Improvement in Mood
  2. 2. Signature: Date: Time: Date:_______________ Time:_______________ Action Taken: Date:_______________ Time:_______________ Outcome of Reassessment:
  3. 3. Examples of a Change of Condition: (Non-inclusive) <ul><li>Change in Blood Pressure </li></ul><ul><li>Elevated Temperature </li></ul><ul><li>Fall with complaint of pain or unable to use limb </li></ul><ul><li>Pain </li></ul><ul><li>Weight Gain or Loss </li></ul><ul><li>Chest pain </li></ul><ul><li>Weakness in any area </li></ul><ul><li>Blood in urine or stool </li></ul><ul><li>Communicable Disease </li></ul><ul><li>Urinary Frequency </li></ul><ul><li>Urinary Fowl Odor </li></ul><ul><li>Pain when voiding </li></ul><ul><li>Depression – Sadness, crying, withdrawn </li></ul><ul><li>Upper Respiratory Infection </li></ul><ul><li>Shortness of breath </li></ul><ul><li>Grief, Loss of Loved One </li></ul><ul><li>Pain down Left arm </li></ul><ul><li>Injury </li></ul><ul><li>Bleeding </li></ul><ul><li>Cyanotic nailbeds or lips </li></ul><ul><li>Dry mouth, lips </li></ul><ul><li>Seizures </li></ul><ul><li>Increased confusion </li></ul><ul><li>Agitation </li></ul><ul><li>Diarrhea </li></ul><ul><li>Lack of stools </li></ul><ul><li>Loss of appetite </li></ul><ul><li>Increased Thirst </li></ul><ul><li>Rashes </li></ul><ul><li>Swelling, redness, weeping sores </li></ul><ul><li>Reddened Skin </li></ul><ul><li>Dry Skin </li></ul><ul><li>Itching </li></ul><ul><li>Cough </li></ul><ul><li>Rattling Chest </li></ul><ul><li>Dizziness </li></ul><ul><li>Altered ambulation/mobility status </li></ul><ul><li>Change in communication </li></ul><ul><li>Change in vision </li></ul><ul><li>Change in the ability to hear </li></ul><ul><li>New or changed behaviors </li></ul><ul><li>Change in continence status </li></ul><ul><li>Headaches </li></ul><ul><li>Sunburn </li></ul><ul><li>Broken bones </li></ul><ul><li>Sprains </li></ul><ul><li>Altered ROM (Range of Motion) </li></ul><ul><li>Joint pain </li></ul><ul><li>Change in hand grasps </li></ul><ul><li>Change or unequal pupils </li></ul>
  4. 4. Admission Date: Dietary Restrictions: (Diabetic/Mech. Soft, etc.) DO NOT RESUSCITATE ORDER: YES NO ASSSITED LIVING PRE-ADMISSION/ADMISSION ASSESSMENT Name: Last, First, Middle Initial Date of Birth: Age: Sex: M F Facility: Address: Person Completing Assessment: Date: Time: Source of History: (Check all that Apply) Resident Resident’s Family Legal Representative Case Manager Community Integration Specialist Health Care Providers/Physician Yes No Psychiatrist, Psychologist Therapist/Counselor OT, PT RN, LPN Medical Record Social Worker Mental Status: Competent Incompetent Guardian: (Name, Address, Phone Number) POAHC: Activated Y N POAF: Activated Y N Power of Attorney: (Name Address, Phone Number) TPR: BP: Height: Weight: Medications: (Current Prescription and Over the Counter) (Reason for taking; diagnosis) Allergies: Immunizations: Date Influenza Tetanus Pneumonia (Pneumovax) Other
  5. 5. Pacemaker Catheter Artificial Limbs Yes No Yes Yes No No Date Date Tuberculin Test (TB) Stools for Occult Blood Breast Exam Pap Smears Mammogram Dental Hearing Vision Screening/Exams: Appliances/Aids Used: Yes No Yes No Glasses Hearing Aids Upper Dentures Lower Denture Partials (Dental) Crutches Cane Walker Wheelchair Medical History: (Check All That Apply or If There Is a History) Diabetes Cataracts Tuberculosis Heart Disease High Blood Pressure Stroke Kidney Disease Cancer Pneumonia Chokes/swallowing difficulties Rash/skin ulcers High Cholesterol Arthritis Seizures Pain Headaches Depression Mental Illness Wandering Harmful Behaviors Hospice Services Home Health Services Oxygen Paralysis Ambulatory Semi-ambulatory Non-ambulatory Falls Blind Hearing Impaired Verbal, make needs known Non-verbal Self Administers Medication Terminal Illness Tube Feedings Current Diagnosis:
  6. 6. Culture: Religion: Military: Social History: (Explain) Spoken Language: Community Activities: Enjoys Which Activities: Sleep Pattern: (Include naps, bedtime and rising times) Habits: Family Contacts: Education: Vocational (past/present): Abilities/Needs: (Independent, without assistance) Yes No Bathing or Showering Self Feeds Self Dresses Self Oral Hygiene Nail Care - hands Foot Care Toileting Incontinence Care Positioning in Bed Body Alignment Ambulates Independently Ambulates with Adaptive Device Independently
  7. 7. Review upon admission for any changes since date of pre-admission assessment. Initial and Date: Yes No Verbalizes Needs Transfers From Bed to Chair Transfers From Chair to Bed Makes Own Decisions Evacuates Facility Administers Own Medications and Stores Appropriately Attends Vocational Training Resident Interests: Areas requiring assistance, to be identified on ISP: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
  8. 8. Admission Date: Dietary Restrictions: (Diabetic/Mech Soft etc.) DO NOT RESUSCITATE ORDER: YES NO ANNUAL ASSESSMENT Name: Last, First, Middle Initial Date of Birth: Age: Sex: M F Facility: Address: Person Completing Assessment: Date: Time: Source of History: (Check all that Apply) Resident Resident’s Family Legal Representative Case Manager Community Integration Specialist Health Care Providers/Physician Yes No Psychiatrist, Psychologist Therapist/Counselor OT, PT RN, LPN Medical Record Social Worker Mental Status: Competent Incompetent Guardian: (Name, Address, Phone Number) POAHC: Activated Y N POAF: Activated Y N Power of Attorney: (Name Address, Phone Number) TPR: BP: Height: Weight: Medications: (Current, Prescription and Over the Counter) (Reason for taking; diagnosis) Allergies: Immunizations: Date Influenza Tetanus Pneumonia (Pneumovax) Other Screening/Exams: Yes No Date Tuberculin Test (TB) Breast Exam Pap Smears Mammogram Stools For Occult Blood Dental Hearing Vision TPR: (Last Year) BP: (Last Year) Weight: (Last Year) Weight In Pounds: (Past Year) Loss Gain Yes No Date Yes No Date Diagnosis Added In Past Year:
  9. 9. Catheter Oxygen Tube Feedings Military: Religion: Culture: Medical History: (Check All That Apply as If There Is a History) Diabetes Cataracts Tuberculosis Heart Disease High Blood Pressure Stroke Kidney Disease Cancer Pneumonia Chokes/swallowing difficulties Rash/skin ulcers High Cholesterol Arthritis Seizures Pain Headaches Depression Mental Illness Wandering Harmful Behaviors Hospice Services Home Health Services Paralysis Ambulatory Semi-ambulatory Non-ambulatory Falls Blind Hearing Impaired Verbal, make needs known Non-verbal Self Administers Medication Terminal Illness Social History: (Explain) Spoken Language: Community Activities: Enjoys Which Activities: Sleep Pattern: (Include naps, bedtime and rising times) Habits: Family Contacts: Education: Vocational (past/present):
  10. 10. Appliances/Aids Used: Yes No Glasses Hearing Aids Upper Dentures Lower Dentures Partial (Dental) Crutches Cane Walker Wheelchair Pacemaker Yes No No Yes Artificial Limbs Yes No Abilities/Needs: (Independent, without assistance) Bathing or Showering Self Feeds Self Dresses Self Oral Hygiene Nail Care - Hands Foot Care Toileting Incontinence Care Positioning in Bed Body Alignment Ambulates Independently Ambulates with Adaptive Device Independently No Yes Verbalize Need Transfers From Bed to Chair Transfers From Chair to Bed Makes Own Decisions Evacuates Facility Attends Vocational Training Administers Own Medications and Stores Appropriately Comments: Comments:
  11. 11. Improvement noted in the Following Areas: 1. 2. 3. 4. 5. 6. Decline noted in the Following Areas: 1. 2. 3. 4. 5. 6. Resident Goals: (To be addressed and updated on ISP) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

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