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RN/LPN & Wound Care Assessment Form
Step
1
of
9
11%
Patient Information
Name
Address
City
State
Zip
Phone
ALT Phone
Date of Birth
MM slash DD slash YYYY
Age
LANGUAGE(s) Spoken/Understood:
Gender
Male
Female
Marital Status
Married
Single
Widowed
Separated
Divorced
Unknown
LIVING ARRANGEMENTS AND HOME LAYOUT
One Family Home
Apartment
Facility
Multi-Family Home
Boarding House
Bath Modifications
Other Modifications
Pets
Clean Conditions
Stairs
Other (specify)
# of Bedrooms
# of Bathrooms
(#Flights)
LIVES WITH:
Spouse
Alone
Others (below)
Name
Age
Relationship
Name
Age
Relationship
Name
Age
Relationship
Home Health Services CURRENTLY Provided:
RN
Freq.
Duration
LVN/LPN
Freq.
Duration
HHA
Freq.
Duration
PT
Freq.
Duration
OT
Freq.
Duration
Other
Freq.
Duration
Comments
EMERGENCY CONTACT
PHONE
RELATIONSHIP
Date
MM slash DD slash YYYY
Date of the Week
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Total
Time Arrived
AM
PM
Time Departed
AM
PM
Total
REASON FOR ASSESSMENT
Initial Evaluation for Nursing
Wound Care
Catheter Care
IV
Trach Care
Consent
Re-evaluation
Date of Last Eval
Consent
Initial Evaluation for Home Health Aide
Other (specify)
DIAGNOSES (List all diagnoses, surgical procedures & complications with dates of onset, related to present condition.)
PRINCIPAL
SECONDARY
OTHER
HISTORY OF PRESENT CONDITION
HOSPITAL/FACILITY Information & Dates
Patient Risk Factors Related to Medical Diagnoses
Tobacco Use
Alcoholism
Cardiac Conditions
Diabetes
Obesity
High B.P.
Chronic Conditions
Drug Dependency
NUTRITION
Ht.
Wt.
NUTRITION
Recent Weight Loss
Overweight
Underweight
Diet
Recent Weight Loss
Overweight
Underweight
Fluid Intake/Day
Meals Prepared By
Patient Name (Print)
Date
MM slash DD slash YYYY
PHYSICAL ASSESSMENT
HEAD
TEMP
Concussion
TBI
EYES
Glasses
Contacts
Cataracts
PERL
EARS
Hearing Loss
Hearing Aid
Mouth (Dentures)
NOSE/THROAT/SINUS
SPEECH
CARDIOVASCULAR
B.P.
Supine
Pulse
Edema
Standing
Heart Sounds
Chest Pain
Heart Murmur
Pacemaker
Tenderness
Palpitations
Comments
PHYSICAL ASSESSMENT CONTINUED
RESPIRATORY RATE:
SOB
Cough
Sputum
Breath Sounds
Comments
GASTROINTESTINAL
Pain
Flatulence
Hematomesis
Diarrhea/Constipation
N&V
Jaundice
Bowel Sounds
Melena
Incontinent
Tenderness
Ostomy
Comments
ABDOMEN
Soft
Flatulence
Hematomesis
Comments
GENITOURINARY
Urgency
Frequency
Hematuria
Lesions
Incontinence
Nocturia
Pain
Vag. Disch/Bleeding
Catheter/Size
Bladder Program
Ostomy
Comments
BREASTS
Soft
Flatulence
Hematomesis
Comments
INTEGUMENTARY: Record on corresponding body area. Indicate size to the right of the number category.
1. Lesions
6. Decubiti
11. Port
2. Bruise
7. Pressure Area
12. Central Cath.
3. Mass
8. Incision
13. Periph Access
4. Scar
9. Rash
14. Phlebitis
5. Ulcer
10. Other (Describe)
15. Phlebitis
Color
Turgor
Temp
Comments
NEUROLOGICAL
Syncope
Comatose
Numbness
Paralysis
Tremor
Aphesis
Comments
ENDOCRINE
History of Diabetes
Excessive Bruising
History of Thyroid
Polyuris
Excessive Bleeding
Polydipsia
Comments
ENDOCRINE
History of Psych Illness
Depressed
Oriented to:
Time
Place
Person
Memory Loss
Comments
Print Name
Date
MM slash DD slash YYYY
ACTIVITIES OF DAILY LIVING (Check Appropriate Boxes)
Level of Independence
Mobility
Chair Transfers
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Stairs
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Walking Inside
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Walking Outside
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Manual Wheelchair
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Electric Wheelchair
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Eating
Using Utensils
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Use Drinking Cups
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Cutting Food/Meat
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Bathroom/Hygiene
Toilet Transfers
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Toilet/Wiping
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Bath Transfers
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Shower Transfers
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Bathing/Washing
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Brush/Comb Hair
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Shaving
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Clean Teeth
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Apply Makeup
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Bathroom/Dressing
UE Dressing
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
LE Dressing
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Don Shoes & Socks
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Tying Laces
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Bed Transfers
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Move/Shift in Bed
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Instrumental Activities of Daily Living ( Check Appropriate Boxes)
Cooking
Cook Simple Meals
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Cook Complex Meals
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Use Appliances
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Cut Veg/Food
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Light Housework
Dusting
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Mop Floors/Vaccum
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Laundry
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Wash Dishes
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Change Bed Sheets
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Shopping
Push Cart
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Carry Items/Bags
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Using Money
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Gardening
Raking Leaves
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Watering Plants
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Using Shears
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Moving Lawn
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Driving
Car Transfers
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Turn Steering Wheel
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Using Foot Pedals
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Using Mirrors
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Communication
Using Phone/Cell
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Handwriting
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Typing
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
TV/Use Remote
Without Aid
Stby Assist
Min Assist
Mod Assist
Max Assist
Total Assist
Uses Device
Patient Name
Date
MM slash DD slash YYYY
Goal of "Home Care" as Identified by Patient/Client
Appliance/Aids/Special Equipment
Ambulation Aid Other
Has
Needs
Prosthetic Device
Has
Needs
Pace Maker
Has
Needs
Tub Bench
Has
Needs
Hospital Bed
Has
Needs
Transferring Equip.
Has
Needs
Toileting Equip.
Has
Needs
Dressing Equip.
Has
Needs
Colostomy Bag
Has
Needs
Cane
Has
Needs
Walker
Has
Needs
Grab Bar
Has
Needs
Commode
Has
Needs
Oxygen
Has
Needs
Whelchair
Has
Needs
Leg Brace
Has
Needs
Other/Soft Goods
Has
Needs
Patient Traits
Appears self directed and/or independent.
Yes
No
N/A
Seems to make appropriate decisions.
Yes
No
N/A
Can recall med routine/recent events
Yes
No
N/A
Participates in planning/treatiment program.
Yes
No
N/A
Seems to handle crises well
Yes
No
N/A
Comprehension of Diagnosis
Yes
No
N/A
Comprehension with Treatment
Yes
No
N/A
Informed caregiver(s) is(are) able to receive instructions and provide care?
Yes
No
Not Known
N/A
Summary of Service Recommendations
Services (Hrs/Days/Wks)
Comments
RN Services (Hrs/Days/Wks)
Comments
LPN Services (Hrs/Days/Wks)
Comments
Home Health Aide (Hrs/Days/Wks)
Comments
Physical Therapy (Hrs/Days/Wks)
Comments
Occupational Therapy (Hrs/Days/Wks)
Comments
Speech Pathology (Hrs/Days/Wks)
Comments
Transportation (Hrs/Days/Wks)
Comments
Other Specify
Assessment Signature
Date
MM slash DD slash YYYY
Assessment Information Obtained From:
Patient
Family
Referral Source
Physician
Other (Specify)
Patient Signature
Date
MM slash DD slash YYYY
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