Patient Name: DOB:
Assessment Date:
TIME:
SOC Date:
  

PT Address: Emergency Contact Name: Phone #:

Last 4 digits of Social Security Number:    Physician Name: Phone #:  Pharmacy: Phone #:

NON SKILLED ASSESSMENT / REASSESSMENT

The following have been discussed with the patient and/or family caregiver prior to Provision of care

  • Rights and responsibilities      
  • Charges for services                              
  • Pt/caregiver development of care plan
  • Complaint procedure                  
  • Goals of visits
  • Services provided      
  • Discharge planning
  • EVV
  • Fire/safety/disaster emergency plan                  
  • Privacy notice
  • Instructions on measures to control infection
  • Advance directive

DIAGNOSIS[11]:

ALLERGIES[17]:

 

ADVANCED DIRECTIVES:  NoYes If yes, list:

MENTAL STATUS [19]:  Person Place Time Situation Disoriented Forgetful Agitated Lethargic Impaired Cognitive/Decision Making Other


WELLNESS AND IMMUNIZATIONS

COVID vaccine:  Yes   No-Educated
Date:
 
Influenza Vaccine:  Yes   No-Educated
Date:
 
Pneumonia Vaccine:  Yes   No-Educated
Date:
 
Colonscopy:  Yes   No-Educated
Date:
 
Mamogram:  Yes   No-Educated
Date:
 
Vision Testing:  Yes   No-Educated
Date:
 
History or current Recreational drug use:  No   Yes
 
History or current Alcohol use:  No   Yes
 
History or current smoker:  No   Yes


VITAL SIGNS

Temp:°F    Pulse:  Blood Pressure: /  Respirations:

Weight:   Height: 

Additional vital signs, if needed

Are there are medication parameters? No   Yes

Pain Scale:
Usual Pain Intensity Present Pain Intensity

Pain Frequency: Pain location: Pain Description:

Intervention:

Effectiveness

Need for palliative care: NO   Yes-Refer


FUNCTIONAL LIMITATIONS [18a]:
Ambulation     Contracture    Bedbound    Legally deaf     Paralysis    Speech     Dyspnea with Minimal Exertion     Bowel Incontinence,    
Bladder Incontinence     Endurance     Amputation     Legally Blind     Cognition/decision making     Other  
 

ACTIVITIES PERMITTED [18b]:   Up As Tolerated    Transfer Bed/Chair    Cane    Wheelchair   Walker   Active Range Of Motion   
Prescribed Exercises    Others 

FALL SCREEN

Any falls within the last 3 months  6 months

 

LIST SAFETY MEASURES/PRECAUTIONS [15]:

Fall precaution   Keep pathways clear    Bleeding precautions   Oxygen precautions     Infection/standard precautions  Seizure Precautions  Sharps  Emergency Plan Developed  Support During Transfer/Ambulation  Slow Position Change  Use Of Assistive Devices  Proper Positioning During Meals   Others (specify) 

LIVING ARRANGEMENTS AND INFORMAL SUPPORT

Lives:

Alone Spouse Family Other: NameRelationship

Family Support:

No Yes: Family Caregiver Name:Relationship: Phone number:

Involvement:

Backup caregiver  Medication management   Vital signs   Treatment / wound care


Competence demonstrated: Yes No,  Education provided with return demonstration

Backup caregiver agreement signed Yes N/A No

Medication Management Self Family/Friend Other Agency (name: )


DME AND SUPPLIES [14]:

Cane Walker Wheelchair Grab Bars Bedside Commode Tub/Shower Bench Hospital Bed Oxygen
Hoyer Lift
Diabetic Supplies Raised Toilet Seat Incontinence Supplies Gait BeltGlucometerNebulizserPERS
OTHERS:
 

 

HEALTH STATUS ASSESSMENT

 

NEUROLOGICAL:

 

VISION & HEARING:

 

MUSCULOSKELETAL:

 

INTEGUMENTARY:

  • Type of skin impairment
  • Measurement (Length,width,depth) Unable to measure
  • Location
  • Condition of surroundina skin
  • Drainage
  • Responsible Party

 

Refer to MD (MLTC) for Eval

 

RESPIRATORY:

 

CARDIOVASCULAR:

 

ENDOCRINE:

 

GENITOURINARY:

 

GASTROINTESTINAL:

 

ELIMINATION STATUS:

 

Urinary Incontinence: Yes No

 

If incontinent, when does Urinary Incontinence occur?    Timed-voiding defers incontinence    During the night only    During the day and night

 

Bowel Incontinence: Yes   No

 

Urinary Catheter/Ostomy: NoYes

 

NUTRITIONAL SCREEN:

Gtube: Yes No

 

Check All that Apply:

 







 


NUTRITION RISK/ INTERVENTION:
 Impaired or inadequate food and fluid intake/difficulty chewing or swallowing 
Issues with availability of food and fluid for patient 
: comorbidity, multiple medications, dentures  

Intervention:    
Refer to MD (MLTC) for eval   Refer to APS/proxy/Nurse manger     Education provided

DIETChoose one diet that is most appropriate[16]:
Regular Diet   

 

PSYCHOSOCIAL

Do you feel lonely or isolated: No Yes, supervisor notified

 

ABUSE, MISTREATMENT AND NEGLECT SCREEN

Signs Absent Signs Present, supervisor notified

 

Intervention

N/A Aps/Social Work Referral Md Notified MCO Notified Abuse Hotline 911 Called

 

 

ADLS/FUNCTIONAL ASSESSMENT

  1. Grooming: Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or make up, teeth or denture care,  fingernail care)  Able to groom self  needs assistance for grooming
  2. Ability to Dress (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, slacks, socks shoes buttons, and snaps: Able to dress self needs help to put on clothing
  3. Bathing: Ability to wash entire body. Excludes grooming (washing face and hands only) Able to bathe self in shower or tub independently Needs assistance or supervision to bathe
  4. Toileting: Ability to get to and from the toilet or bedside commode. Able to get to and from the toilet independently Needs assistance or supervision to use the toilet
  5. Transferring: Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if member is bedfast Able to independently transfer with or without assistive device Transfers with assistance of a person or totally dependent for transfer
  6. Ambulation/Locomotion: Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces. Able to walk alone with or without assistive device or able to wheel self Requires assistance to walk or wheel a chair Non ambulatory
  7. Feeding or Eating: Ability to feed self meals and snacks. Note: This refers only to the process of eating, chewing, and swallowing, not preparing the food to be eaten. Able to independently feed self requires assistance or supervision
  8. Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals Able to independently prepare or heat meals Needs assistance
  9. Laundry: Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand. Able to independently take care of laundry tasks requires assistance
  10. Housekeeping: Ability to safely and effectively perform light housekeeping and cleaning tasks Able to independently perform housekeeping tasks requires assistance
  11. Shopping: Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery Able to independently perform shopping tasks requires assistance or needs someone to do all shopping and errands

 

 

 

PROGNOSIS [20]:

Poor Guarded Fair Good

 

REHAB POTENTIAL [22]:

Poor- Improvement in functional status is not expected; decline is probable
Fair- Minimal improvement in functional status is expected; decline is possible
Good- Improvement in functional status is expected

 

GOALS [22]:

Patient will:
Remain safe in the community
Comply with his/her diet and medication regimen
Not be hospitalized during this assessment period

 

DISCHARGE PLAN [22]:
At request of patient or vendor
To another agency or level of care when this agency can no longer care for the client

 

SERVICES AND FREQUENCY [21]:

Nurse HHA PCA

EMERGENCY PREPAREDNESS:

PRIORTY CODE

TALS

Electronic device dependency: Bi-pap IV-pump TPN Feeding pump Oxygen Ventilator

 

Where would you evacuate in the event of an emergency:
Facility provided by emergency management
Family (name and number)
Friend (name and number)

 

Progress Note

 

COORD

I have participated and agreed with the plan of care developed together with my nurse, and received a copy that will remain in my home.

I have seen and understand the EVV Fact Sheet What You Should Know About Electronic Visit Verification (EVV) posted on the Department’s EVV website: EVV Fact Sheet for Medicaid Beneficiaries and Families.

Patient Signature:

Reset Signature

 Authorized Agent Signature:
 

Reset Signature

Reason Patient unable to sign

If patient is unable to sign and this box is checked please enter N/A in the patient signature box    		 Print Name:
Relationship:
Today's Date
RN Signature

Reset Signature

Print RN Name:
 

MEDICATION PROFILE

 

DRUG NAME DOSE AMOUNT and FORM FREQ ROUTE PARAMETERS, if any COMMENTS (include new or change)

Medication reconciliation including schedules, potential adverse effects, drug reactions, ineffective or duplicate drug therapy, and significant side effects reviewed with patient/family.

ENVIRONMENTAL SAFETY ASSESSMENT

KEY: Yes=Safe, No= Unsafe, N/A= to this patient or environment

  YES NO N/A   YES NO N/A
Clean Uncluttered walking path
Flushing toilet Toilet seat proper level
Tub/shower Seat in tub/shower
Handgrips in tub/shower Adequate night lights
Smoke detectors Air-conditioning
Heat Adequate furnishings
Wheeled furniture has locks enabled Furniture without sharp edges
Unbuckled carpets Scatter rugs with non stick backs
Non-skid treads on steps Stairs with hand rail
Adequate lighting Lights easily reached
Adequate electricity Visible Outlets not overloaded
Visible electrical cords un-frayed Outlets properly accessed
Electric cords along walls Adequate storage space
Storage waist to eye level Refrigerator
Stove Phone easily accessible
Posted emergency numbers Hazardous waste disposal
Lifeline/PERS Fire evacuation plan
Disaster evacuation plan Other:

 

 

HOME TYPE:

Private home      Single level Multi level

 

Apartment      Elevator No elevator

Number of Rooms


Safety Assessment Comments:

COORD


                                                                                           
 

        

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