Nursing Assessment for Home Care - New York State ...

Nursing Assessment for Home Care

Page 1 of 3

Patient Information:

Last Nam e:

First Nam e:

ADAP ID Num ber: 555-

Middle Initial:

Social Security Num ber:

Contact Person (Nam e & Relationship):

Contact Phone (Day-tim e):

Please submit release to allow Program contact.

Living Situation:

Dwelling: ? Apartm ent ? House ? Other:

Lives alone:

? Yes ? No

Floor:

Elevator: ? Yes ? No

# of Room s:

Identify all individuals living in the hom e:

List the services, hours and days they are available and able to assist with care giving:

Hospitalization:

Hospital Nam e:

Address:

Hospitalized: From :

To:

Diagnoses:

Hospital Contact:

Phone:

Patient Status:

Is patient alert?

? Always

? Som etim es

Can patient direct a hom e care worker?

? Yes

? No

If no, who is responsible for directing home care workers?

? Never

Nam e/Relationship:

Patient Height:

Patient W eight:

Recent significant weight loss?

? Yes

? No

If Yes, am ount lost:

Impairments:

Sensory:

1. Speech

2. Sight

3. Hearing

Muscular/Motor:

None

Partial

Total

?

?

?

?

?

?

?

?

?

None

Partial

Total

?

?

?

?

?

?

?

?

?

1. Hand/Arm

2. Upper Extrem ities

3. Lower Extrem ities

None

Partial

?

?

?

?

?

?

Total

?

?

?

Cardiovascular / Respiratory:

1. Respiratory

2. Cardiac

3. Circulatory

Describe im pact on functional ability.

________________________________________________

________________________________________________

1. Does patient have history of tuberculosis?

? Yes ? No

2. Did patient com plete therapy?

? Yes ? No

3. Does patient currently have tuberculosis?

? Yes ? No

4. Is patient currently on tuberculosis prophylaxis? ? Yes ? No

5. Last docum ented PPD: Date and result ________________

? Pulm onary ? Extra pulm onary

? Pulm onary ? Extra pulm onary

Hx of TB prophylaxis ? Yes ? No

Anergy results if available:____________________

6. If on tuberculosis treatm ent, are there 3 negative AFB? ? Yes ? No

Negative chest x-ray

? Yes ? No

New York State Department of Health

Uninsured Care Programs

Nursing Assessment - Page 2 of 3

Patient Name:______________________________________________________ ADAP ID#: 555-_________________

Agency: ___________________________________________________________ Provider Num ber: ______________

Mental Status

1.

2.

3.

4.

5.

6,

7.

Oriented place and tim e

Anxiety

Agitated

Short term m em ory loss

W anders

Depression

Im paired judgm ent

Never

Partial

Total

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

Never

Partial

Total

?

?

?

?

?

?

?

?

?

?

?

?

?

?

8. Danger to: Others (Aggressive)

Self

9. Articulates needs

10. Sleep disorder

11. Abusive to:

Others

Self

12. Other Cognitive / Mental

Status Inform ation:

?

?

?

?

Patient Ability to Take/Administer Medication:

Never

1.

2.

3.

4.

5.

Totally independent

Needs rem inding

Non-com pliant

Needs help preparing

Needs adm inistration

Som etim es*

?

?

?

?

?

Always

?

?

?

?

?

?

?

?

?

?

*Com plete #7.

6. Patient/care giver can be

taught to adm inister

? Yes

7. Please explain:

? No

If patient is not independent, what arrangem ents have been m ade to adm inister m edications?

IV Infusion and Injections:

# of Times Per W eek

Patient requires hom e infusion via:

? Central Line

? Peripheral Line

Injections

______________

Blood work (in the hom e)

______________

______________

Elimination:

Continent

Occasionally Incontinent

Incontinent

Bowel

Bladder

?

?

?

?

?

?

Medical Treatment: (Check T all that apply) Please list all medications on AI485:

1. Decubitus care

?

6. Monitor vital signs

?

11. Blood tests

?

2. Dressings - Sim ple

?

7. Tube feeding

?

12. Am bulation exercise

?

3. Dressings - Sterile

?

8. Tube irrigation

?

13. Rehabilitative therapy

?

4. Enem a

?

9. Suctioning

?

14. Physical therapy

?

5. Catheter care

?

10. Oxygen adm inistration

?

New York State Department of Health

Uninsured Care Programs

Nursing Assessment -

Page 3 of 3

Patient Name:_____________________________________________________ ADAP ID#: 555-_________________

Agency: __________________________________________________________ Provider Num ber_______________

Identification of Service Needs:

W ithout

Help

W ith

Cane

W ith

W alker

W ith

W heelchair

W ith

Personal

Assistance

Unable

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

Am bulate inside

Am bulate outside

Get up from seated position

Get up from bed

Transfer to:

Com m ode

W heelchair

Indicate Patient¡¯s Personal Service Needs:

Groom ing

Dressing

W ashing

Bathing

Feeding

Meal Prep

Reheat Meals

Independent

Partial

Assist

Total

Assist

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

Toileting/ Bathroom

Urinal or bedpan

Com m ode

Catheter

Laundry

Shopping

Housecleaning

Independent

Partial

Assist

Total

Assist

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

?

Is the patient homebound?

? Yes

? No*

*If patient is not hom ebound, you m ust subm it justification of hom e care separately.

Certification:

This assessm ent is based on personal observation of the patient.

? Yes

? No

This assessm ent is based on inform ation relayed to m e by: ______________________________________________

Prepared by: (print nam e)___________________________________________ Phone #:_____________________

Agency Affiliation:_________________________________________________ FAX#: _______________________

Signature:________________________________________________________ Date: ________________________

Is any other agency/vendor providing services in the hom e to the patient?

? Yes

? No

If Yes, Agency Nam e:___________________________________Services:__________________________________

Have all hom e care insurance benefits been exhausted?

? Yes ? No

Is this patient eligible for Medicaid? ? Yes ? No

Have they applied to Medicaid? ? Yes ? No

If No, state reasons:_____________________________________________________________________________

FOR NEW HOM E CARE APPLICANT ONLY:

How was the applicant referred to your agency?

? Doctor

? Social W orker

? Discharge Planner Location:___________________________________________

? Other Please explain:___________________________________________________________________________

(Rev. 12/2005)

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