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About
Skilled Nursing
Home Care
Companion Care
Homemaking
Meal Planning and Preparation
Personal Care
Respite Care
Careers
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Service Areas
Contact
Schedule Consultation
Participant Assessment Form
Participant Assessment Form
Step
1
of
10
10%
Participant Name:
GENERAL HEALTH
Temperature:
Pulse:
Respiration:
Blood Pressure:
Current Weight:
Choose the following:
Gain
Loss
Target Weight:
Diet/Nutrition:
Regular
Low Salt
Puree/Chopped
Diabetic/No Concentrated Sweets
Other
Other, please specify:
Fluid:
Unlimited
Restricted
Amount:
Identify any changes over past month:
Diagnosis
Medications
Health Status
Hospitalization
Falls
Incidents
Describe change:
RESPIRATORY
Choose the following:
Within Normal Limits
Cough
Choose the following:
Wheezing
Other
Other, please specify:
When is the person noticeably short of breath?
Never short of breath
When walking > than 20ft. or climbing stairs
With moderate exertion (e.g. dressing, using commode, walking < 20ft)
With minimal exertion (eating, talking)
At rest (during day/night)
Respiratory treatments utilized at home:
Oxygen (intermittent or continuous)
Aerosol or nebulizer treatments
Ventilator (intermittent or continuous)
CPAP or BIPAP
None
PAIN/DISCOMFORT
Pain frequency
No pain or pain does not interfere with movement
Less often than daily
Daily, but not constant
All the time
Site(s):
Intensity
High
Medium
Low
Person is experiencing pain that is not easily relieved, occurs at least daily, and effects the ability to sleep, appetite, physical or emotional energy, concentration, personal relationships, emotions, or ability or desire to perform physical activity
Cause (if known):
Treatment:
GENITOURINARY STATUS
Choose the following:
Catheter
Content
Urine
Frequency
Pain/Burning
Discharge
Distention/Retention
Hesitancy
Hematuria
Person has ben treated for a Urinary Tract Infection over the past month
Normal
Other, please specify here:
CARDIOVASCULAR
Choose the following:
BP and Pulse within normal limits
Rhythm
Regular
Irregular
Edema
RUE
Non-pitting
Pitting
LUE
Non-pitting
Pitting
RLE
Non-pitting
Pitting
LLE
Non-pitting
Pitting
Other:
GASTROINTESTINAL STATUS
Bowels: frequency
Choose the following:
Diarrhea
Constipation
Nausea
Vomitting
Swallowing
Pain
Anorexia
Other
Bowel incontinence frequency:
Very rarely or never incontinent of bowel
Less than once per week
One to three times per week
Four to six times per week
On a daily basis
More than once daily
Person has ostomy for bowel elimination
Swallowing Issues, please specify here:
Pain Issues, please specify here:
Choose the following:
Abdominal
Epigastric
Other, please specify here:
NEUROLOGICAL
Cognitive functioning
Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently
Requires prompting (cueing, repetition, reminders)only under stressful or unfamiliar situations
Requires assistance, direction in specific situation, requires low stimulus environment due to distractibility
Requires considerable assistance in routine situations. Is not alert and oriented or is unable to shift attention and recall more than half the time.
Totally dependent due to coma or delirium
Speech:
Clear and understandable
Slurred
Garbled
Asphasic
Unable to speak
Pupils:
Equal
Unequal
Movements:
Coordinated
Uncoordinated
Extremities
Right Upper:
Strong
Weak
Tremors
No movement
Left Upper:
Strong
Weak
Tremors
No movement
Right lower:
Strong
Weak
Tremors
No movement
Left Lower:
Strong
Weak
Tremors
No movement
SENSORY
Vision with corrective lenses if applicable
Normal vision in most situations; can see medication labels, newsprint
Partially impaired; can't see medication labels, but can see objects in path; can count fingers at arms length
Severely impaired; cannot locate objects without hearing or touching or person non-responsive
Hearing with corrective device if applicable
Normal hearing in most situations, can hear normal conversational tone
Partially impaired; can't hear normal conversational tone
Severely impaired; cannot hear even with an elevated tone
PSYCHOSOCIAL
Behaviors reported or observed
Indecisiveness
Diminished interest in most activities
Sleep disturbances
Recent change in appetite or weight
Agitation
A suicide attempt
suicide attempt None of the above behaviors observed or reported
Is this person receiving psychological counseling?
Yes
No
MUSCULOSKELETAL
Choose the following:
Within Normal limits
Unsteady Gait
Poor endurance
Altered Balance
Weakness
Deformity
Contracture
Impaired ROM
Poor coordination
Other
Other, please include:
MENTAL HEALTH
Choose the following:
Angry
Panic
Agitated
Tics Spasms
Depressive feeling reported or observed
Depressed
Flat affect
Paranoid
Mood swings
Uncooperative
Anxious
Obsessive/Compulsive
Hostile
Phobia
None of the above
SKIN
Color
Normal
Pale
Red
Irritation
Rash
Skin Intact
Yes
No (if no, complete next section)
Number of Pressure Ulcers (0, 1, 2, 3, 4 or more)
Stage 1: Redness of intact skin; warmth, edema, hardness, or discolored skin may be indicators
Choose the following number of Pressure Ulcers (0, 1, 2, 3, 4 or more)
Stage 2: Partial thickness skin loss of epidermis and/or dermis. The ulcer is superficial and appears as an abrasion, blister, or shallow crater.
Choose the following number of Pressure Ulcers (0, 1, 2, 3, 4 or more)
Stage 3: Full thickness skin loss; damage or necrosis of subcutaneous tissue; deep crater
Choose the following number of Pressure Ulcers (0, 1, 2, 3, 4 or more)
Stage 4: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures
Choose the following number of Pressure Ulcers (0, 1, 2, 3, 4 or more)
Location of ulcers:
Surgical or other types of wounds (describe location, size and nature ofwound)
Mobility and Transfers:
Dependent
Independent
Assist
Stand-by
One person
Two person assist with transfer
Uses to aid in ambulating.
Uses to aid in transfer.
Bathing:
Dependent
Independent
Assist
Cue
Uses transfer bench or shower chair
Personal Hygiene: hair, nails, skin, oral care
Dependent
Independent
Assist
Cue
Toileting: bladder, bowel routine, ability to access toilet
Dependent
Independent
Assist
Cue
Incontinent bowel
Incontinent bladder
Dressing:
Dependent
Independent
Assist
Cue
Eating and Drinking:
Dependent
Independent
Assist
Cue
HEALTH MAINTENANCE NEEDS
Reinforce diet education
Supervision of blood sugar monitoring
Routine care of prosthetic/orthotic device
Education on medical equipment use or maintenance
Referral to physician
Other health education needed
Other
Notes:
GENERAL PHYSICAL CONDITION
improving
stable
deteriorating
Other
Other, please specify:
MEDICATION MANAGEMENT
Medication
Dose
Frequency
Physician
Purpose
Choose the following:
Able to independently take the correct medications at the correct times
Able to take medications at the correct time if: -individual doses are prepared in advance by another person; -given daily reminders
Unable to take medication unless administered by someone else
No medications prescribed
Other
Other, please specify:
Notes:
Nurse Monitor Visit:
initial
monthly
45 day
3 month
4 month
annual assessment
Activities of Visit:
Developed Caregiver Support Plan
Provided Information and Training to Caregiver
Reviewed Caregiver Support Plan
Assessed/Monitored Caregiver
Assessed/Monitored Participant
Caregiver Names (Please list all caregivers in this section)
By signing below, both the participant and nurse certify that services were delivered.
RN Name (Print):
RN Signature:
Date:
MM slash DD slash YYYY
Please send the white copy of the signed form to the case manager within 10 days of completing the participant's assessment.
Participant Signature:
Date
MM slash DD slash YYYY
Immediately report suspected abuse, neglect, and exploitation to Adult Protective Services at 1-800-917-7383.
Immediately contact the case manager to report health and safety concerns.
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