LIVING ARRANGEMENTS (This Section to Be Completed on Initial Assessment Only)
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* Initial assessments and Annual re-assessments must be completed thoroughly. Assessments completed because of a change in condition will be addressed only in areas of change.*
RESIDENT ASSESSMENT Name Date of Birth Date of Assessment
Primary Diagnosis Secondary Diagnosis
Reason for Assessment History Received From: Initial Annual Noteworthy Change LIVING ARRANGEMENTS (this section to be completed on initial assessment only) Current Home Conditions Safety Hygiene Clean Unclean Good Fair Poor Good Fair Poor
Comments: ______
Temperature Pulse BP Respiration Height (ft/in) Weight (lb)
ALLERGIES Medications Foods
Pollens Other
Comments: ______HABITS Do you smoke? Amount Number of Years Last Usage Yes No Do you drink alcohol? Amount Number of Years Last Usage Yes No Do you use recreational drugs? Type(s) Number of Years Last Usage Yes No If a current smoker, evaluate ability to smoke independently. Any special safety provisions required?
HOBBIES/INTERESTS:
Hobbies/activities enjoyed: Community Contacts:
CULTURAL/SPIRITUAL
Religious/Cultural Affiliation Are there any religious, cultural, or ethnic practices that will affect your care?
MEDICAL HISTORY:
Page 1 of 8 Resident Assessment
SURGICAL HISTORY
SURGERY DATE SURGERY DATE
1. 6.
2. 7.
3. 8.
4. 9.
5. 10. MEDICATIONS
Who is responsible to purchase medications? Who is responsible to store medications? Who is responsible to administer medications? Primary Pharmacy: Phone Number:
MEDICATION DOSAG ROUTE FREQUENCY DATE OF RX PHYSICIAN
Any over-the-counter medications commonly used, and reasons for use:
Have there been any recent changes in medications? ...... Yes No If yes, explain:
COMFORT Pain/Discomfort Intensity (1-10) Location What relieves your pain? Yes No How do others recognize that you are in pain? SLEEPING PATTERNS:
Page 2 of 8 Resident Assessment
COMMUNICATION Speech Education Level Primary Language Hearing Vision
Modes of expression:
Able to make self understood? Yes No Explain: Able to understand others? Yes No Explain: Comments:
ABILITIES: Activities of Daily Living ACTIVITY Independent Needs Dependent RECOMMENDATIONS COMMENTS Assistance Eating Ambulation Transfer Grooming Oral Hygiene Toileting Dressing Bathing Food Preparation Medications Manage Finances Healthcare Visits DAILY ROUTINES: typical 6 AM 6 PM 7 AM 7 PM 8 AM 8 PM 9 AM 9 PM 10 AM 10 PM 11 AM 11 PM 12PM 12 AM 1 PM 1 AM 2 PM 2 AM 3 PM 3 AM 4 PM 4 AM 5 PM 5 AM ORTHOPEDIC Equipment Used/Comments:
Page 3 of 8 Resident Assessment
NEUROLOGICAL Mental Status Oriented Alert Cooperative Agitated Anxious Confused Restless Confused/Disoriented To: Level of Consciousness:
Motor Movement Right Arm: Left Arm: Right Leg: Left Leg: Paralysis Location Syncope Vertigo Tremors Yes No Yes No Yes No Yes No Seizures Type Duration Last Seizure Yes No Comments:
RESPIRATORY Airway Breathing Sounds Right: Left: Oxygen Therapy Type Liters per Minute: Assistance Required: Yes No Yes No Comments:
CARDIOVASCULAR Dizziness Shortness of Breath Edema Cyanosis Yes No Yes No Yes No Yes No Comments:
GASTROINTESTINAL Diet Appetite # Meals/day # Snacks/day Dietary Supplements Recent Wt loss/gain
Mouth Problems If yes, explain: Yes No Swallowing Difficulties: If yes, explain: Yes No Dentures Teeth Problems If yes, explain: Upper Lower None Yes No
Page 4 of 8 Resident Assessment
Bowel Schedule/Patterns Bowel Management Program Specify: Yes No Check all that apply: Use of Incontinence Products? Specify Incontinent Laxative use Constipation Diarrhea Yes No Comments/preferences:
GENITOURINARY Bladder Dribbling Incontinent Frequency Burning Nocturia UTI Hematuria Stones Stoma Difficulty Retention Distention Starting Stream Onset of Symptoms
Catheter Type Size Last Changed Yes No Dialysis Frequency Location of Dialysis Service/Phone contact Yes No Comments:
SKIN Color Temperature Turgor
PROBLEMS LOCATION(S) PROBLEMS LOCATION(S) Edema Ecchymosis Dry Skin Abrasion Flaky Skin Laceration Rash Pressure Ulcer Lesion Wound Scars Dressings Burns Stoma
Page 5 of 8 Resident Assessment
Colostomy Wounds/ Location Length Width Depth Frequency Bag Decubitus Dressing: List any previous or potential skin conditions:
Comments:
SAFETY ISSUES Does the participant have the ability (physical, cognitive, etc) to leave the boarding home without supervision? ...... Yes No
Explain:
Can participant access emergency response without assistance? ...... Yes No
Explain:
Can participant access emergency exits independently? ...... Yes No
Explain:
List any additional safety needs:
DECISION-MAKING CAPABILITIES
Can make own decisions: Alternate Decision Maker/Contact #: Advance Directives in place, if any:
Yes No Scope of decision-making abilities:
Page 6 of 8 Resident Assessment
ADDITIONAL ASSESSMENT TOOLS USED (please see attached forms, as necessary)
Mental Health Dementia Other
Yes No Yes No Yes No
NURSING NEEDS/DELEGATION ISSUES:
RECOMMENDATIONS:
Page 7 of 8 Resident Assessment
COMMENTS:
______
______Signature of prospective resident/resident Signature of responsible party/family
______Signature of Person Completing Assessment Credentials Date
______Signature of Registered Nurse, if applicable Date (Only if different from person completing Assessment)
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