COMMUNITY HEALTH AND SAFETY ASSESSMENT Date:
|Name: | |DDS # | |
| | | | |
|Telephone: | |Age: | |
| | | | |
|Evaluating RN: | |Date Completed: | |
|Source of information ( indicate all that apply) |Reason for Assessment |
| Individual | Baseline Assessment |
| Records | Program/ Services Prescreening |
| Family Member: | Clinical Referral |
| Case Manager: | Discharge | Change of status |
| Provider: | Other: |
|Living Situation | CRS/IHS |
| Community Companion Home | Family home | Own home |
| Community Living Arrangement | ICF/ MR | Other (specify) |
Legal Status: Non-ajudicated Plenary guardian Limited medical guardian Conservator
|Name: | |Relationship: | |
|Address: | |
|Phone: | |E-mail: | |
|Family Contact: | |Relationship: | |
|Address: | |
|Phone: | |E-mail: | |
|Emergency Contact: | |Relationship: | |
|Address: | |
|Phone: | |E-mail: | |
|Employer/Day Program: | |
|Contact Person: | |Phone: | |
|Insurance Information: |
| Medicaid (Title XIX) Number: | |
| Medicare Number: | |
| Private Company: | |
| Number: | |Subscriber: | |
| Medicare D Carrier: | |Number: | |
|Race: African American Asian Hispanic Native American White Other: (specify) | |
MR Level : Profound Severe Moderate Mild Borderline Non-MR
|Communication: Verbal Sign Written Assistive technology: | |
|Ambulation Status: | |
|History of Falls: No Yes (specify frequency and follow-up) | |
|Name: | |DDS # | |
II. Current Medical Information
|Diagnoses: | |
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|Advance Directives/DNR: | | None |
|Seizure Disorder: NA Type: | |Frequency: | | VNS |
|History of Illnesses/ Injuries/ Hospitalizations (recent): | |
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Family Health Issues:
Family Health History Form attached Records Incomplete/ unknown
| Other: | |
Current Medications: (attach additional pages as needed)
|Drug |Dose |Route |Time/ Freq. |Date Started |Reason for Use |
| | | | | | |
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Medication regimen: (indicate one) has has not been stable over past 3 months
|Medication concerns: (include dependency/addiction and compliance concerns) | |
| |
|Pharmacy: | |Phone: | |
|Allergies (Identify antigen and clinical reaction): | |
| EpiPen | |
|Name: | |DDS # | |
|Adaptive equipment: (list all) | | None |
| |
Medical equipment: (include glucose monitoring, enteral feeding, respiratory supplies seizure device, medical alert device etc.) Indicate type and frequency of use: None
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|Bed Side Rails use: (specify type and frequency) | |
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| Requires hospital bed Requires special mattress (specify) | |
Immunizations: Records incomplete/ status unknown
|Type |Date Given |Type |Date Given |
|Tetanus/ Diphtheria (DT) | |DPT | |
|Pneumovax | |Influenza | |
|Measles (Rubeola) | |Rubella | |
| Polio | |Mumps | |
|Hepatitis B * If no Hep B vaccination list status: |
|Tuberculosis (PPD) |Other: |
Diet: Regular (no restrictions) High Calorie (2500- 3000 calorie) Reduced calorie (1000- 1500 calorie)
| Therapeutic Diet (low cholesterol, low fat, no added salt, etc.) specify: | |
| Enteral feeding (specify type, product and frequency): | |
| Other information/ concerns about nutritional status, eating habits, weight, support needs: | |
| | |
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Food and Liquid consistency: Whole (no alterations) Cut-Up (“1/2x 1/2x1/2”) Chopped (“1/4x 1/4x 1/4”)
| Ground ( Pureed ( Mixed (specify): | |
Thin liquids (non- restrictive) Nectar Honey Pudding
Changes in prescribed consistencies within the past 3 months yes no
|Consistency considerations for medications: | |
Swallowing Risks: (specify all that apply)
Eating: Rapid eating Gorging/stuffing food Recurrent refusal of food/liquids/meds
Loss of food/liquid from mouth while eating Motor/sensory concerns
Chewing: Difficulty chewing Absent/no chewing No teeth or few teeth
Swallowing: Choking Coughing during or after meals Gagging on food/ liquid
Difficulty swallowing Excessive throat clearing when eating or drinking
Behavior: Agitation Lethargy Inattention Distractability Vocalizations during meals
| PICA Other (specify): | |
None of the risks specified above have been observed/reported for this individual
Current Health Care Providers:
|Primary: | |Phone: | |
|Address: | |Last Seen: | |
|Name: | |DDS # | |
Others: Include Dentist, Neurologist, Psychiatrist, Psychologist, Podiatrist etc. ( specify name, address phone, and date last seen and frequency of review/follow-up office visits) Attach additional sheet as needed
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Health Related Supports and Evaluations: Include Nursing, Physical Therapy, Occupational Therapy, Speech, Dietitian (specify name, address phone, and date last seen and frequency of review/follow-up) Attach additional sheet as needed
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III. Review of Systems
|Date: |
| ht: | |wt: | |Ideal Body Weight: | | Not determined |
| | | | | | | |
Instructions: Document findings WNL (within normal limits/ negative; NWNL (not within normal limits).
Further explanation needed for all NWNL findings.
Source of Information: (Indicate all that apply) Visual assessment Report of individual Medical Record
Report of other (specify):
|Name: | |DDS # | |
|System |WNL |NWNL |Comments |
|General | | | |
|Appearance | | | |
|Hygiene/ grooming | | | |
|Skin | | | |
|Dryness, itching | | | |
|Rash | | | |
|Wounds/ scars | | | |
|Acne | | | |
|5. Breakdown/pressure ulcer | | | |
|Head/ Scalp | | | |
|c/o headache, dizziness | | | |
|hx: Head injury | | | |
|3. Scalp: dandruff | | | |
|Throat/ Mouth | | | |
|Gums/ mucosa: swollen/ bleeding/ | | | |
|discoloration | | | |
|Teeth: missing teeth/ | | | |
|Dentures (indicate use) | | | |
|Oral hygeine | | | |
|4. Daily dental Rx regimen | | | |
|Eyes: | | | |
|Gross vision | | | |
|Visual impairment | | | |
|c/o itch/pain/tearing | | | |
|Sclera: red | | | |
|Presence/ hx of cataracts/glaucoma | | | |
|Ears: | | | |
|Gross hearing | | | |
|Hearing impairment | | | |
|History of ear aches tinnitus/ vertigo | | | |
|/infection | | | |
|Wax/discharge | | | |
|Corrected hearing/ compliance using device | | | |
|Tactile/ Kinesthetic | | | |
|1. Sensitivity to light/touch/ | | | |
|sound/ smell (specify) | | | |
|Name: | |DDS # | |
| | | | |
|System |WNL |NWNL |Comments |
|Nose | | | |
|Allergies: congestion | | | |
|hx sinus problems | | | |
|3. hx nose bleeds | | | |
|Feet | | | |
|Nail care | | | |
|Nails- fungal/ ingrown | | | |
|Calluses/ bunions/corns/ deformities | | | |
|4. Swelling | | | |
| | | | |
|Cardiovascular | | | |
|hx chest pain/ PRN RX | | | |
|hx Palpitations | | | |
|hx hypertension | | | |
|hx heart disease | | | |
|Pacemaker | | | |
|Respiratory | | | |
|Chronic cough | | | |
|Dyspnea/Cyanosis | | | |
|Chronic congestion | | | |
|hx asthma/ bronchitis | | | |
|hx aspiration pneumonia | | | |
|Sleep Apnea | | | |
|Oxygen use | | | |
|Suctioning | | | |
|Postural drainage | | | |
|Tracheostomy | | | |
|Gastrointestinal | | | |
|Dysphagia | | | |
|c/o nausea/ heartburn | | | |
|hx vomiting/ dehydration | | | |
|hx GERD | | | |
|G/J/ NG tube | | | |
|Recent weight ( or ( | | | |
|Bowel patterns | | | |
|hx anal/ rectal bleeding | | | |
|Colostomy/ ileostomy | | | |
|Peripherovascular | | | |
|Extremities: edema/ cold | | | |
|c/o pain/ cramps/ numbness | | | |
|Varicosities | | | |
|Genitourinary | | | |
|Voiding pattern | | | |
|Incontinence; catheter | | | |
|Kidney disease; Dialysis | | | |
|Hernia | | | |
|hx UTI/ hematuria, stones, | | | |
|Neurosensory | | | |
|hx fainting | | | |
|Tremors/ TD/ EPS | | | |
|Memory: short/ long term | | | |
|Seizures/ concerns | | | |
|ParkinsonsOther | | | |
|Name: | |DDS # | |
|System |WNL |NWNL |Comments |
|Musculoskeletal | | | |
|c/o pain/ stiffness/ cramps | | | |
|Range of motion | | | |
|Gait/ coordination/ balance | | | |
|Joint stiffness/ Arthritis | | | |
|Back problems/ scoliosis | | | |
|hx fracture/Osteoporosis | | | |
|Endocrine/ Hemotologic | | | |
|Heat/ cold tolerance | | | |
|Excessive sweating/ thirst hunger/ urination| | | |
|hx thyroid/ diabetes/ anemia | | | |
|Bruising/ bleeding pattern | | | |
|Compromised immune system/ Autoimmune | | | |
| | | | |
|Female Health Issues | | | |
|Menses: pattern/ nature | | | |
|Menopause: peri/ post | | | |
|Hormonal therapies | | | |
|Birth control: specify method | | | |
|Hysterectomy | | | |
|Breasts: lumps/ discharge/hx | | | |
|Last mammogram | | | |
|Last PAP/ exam | | | |
|Self-exam skills | | | |
|Pregnancy/miscarriage/ abortion | | | |
|STD/ sores/ discharge | | | |
| | | | |
|Male Health Issues | | | |
|Prostate: recent exam/ hx | | | |
|Testicular self exam skills/ issues | | | |
|Vasectomy | | | |
|STD/ sores/ discharge | | | |
| | | | |
|Emotional Mental Status | | | |
|Orientation | | | |
|Hallucinations | | | |
|Nervousness/ anxiety | | | |
|Sadness/ Loneliness | | | |
|Fearful/ Withdrawn | | | |
|Irritable/ angry | | | |
|Sleep Pattern | | | |
|Usual stressors | | | |
|9. Dementia | | | |
|Maladaptive behavior | | |Indicate frequency, duration, precipitators and plan |
|Aggressive/assualtive | | | |
|Destructive | | | |
|Self-Injurious | | | |
|PICA | | | |
|Running away | | | |
|Verbal abuse | | | |
|Other (specify) | | | |
|Other pertinent information/comments: | |
| |
|Name: | |DDS # | |
IV. Health Skills Assessment
| Individual: |Yes |No |
|1. Participates in the selection of health care providers as possible | | |
|2. Contacts primary care provider independently for appointments, concerns | | |
|3. Requires assistance to contact primary care provider | | |
|4. Understands own diagnoses and health status (specify) | all | some | | |
|5. Understands prescribed treatments | all | some | | |
|6. Requires assistance to understand treatments (if “yes” specify all who assist) | | |
|staff nurse family guardian | | |
|7. Complies with health recommendations and treatment to promote optimal health | | |
|8. Understands impact of non-compliance with health recommendations/ treatments | | |
|9. Receives training/counseling about non-compliance with health issues (if “yes” | | |
|specify from whom) Support team MD RN other: | | |
|10. Attends medical appointments independently ( if “no” specify type of assistance needed) | | |
|transportation staff to accompany other : | | |
|11. Promptly, appropriately, and accurately reports abnormal health conditions | | |
|(If yes, specify to whom reports) Staff Family/Guardian Primary care provider | | |
|12. Knows how to use 911 to contact emergency personnel | | |
|13. Has emergency device to contact assistance (specify): | | |
|14. Knows how to evacuate self from danger: fire, intruders, etc. | | |
|15. Performs first aid techniques: control bleeding, clean wound, apply band-aid | | |
|16. Participates in exercise (specify) | | |
|17. Knows, understands and practices safe sexual behaviors | | |
|18. Knows and understands risks and outcome of alcohol abuse | | |
|19. Knows and understands risks and outcome of drug abuse | | |
|20. Knows and understands risks and outcome of smoking | | |
ADL skills: (Specify level of assistance needed)
| |Independent |Needs |Needs supervision |Needs physical assistance |Needs total assistance |
| | |Prompts | | | |
|Bathing | | | | | |
|Grooming | | | | | |
|Shaving | | | | | |
|Dressing | | | | | |
|Eating | | | | | |
|Tooth brushing | | | | | |
|Toileting | | | | | |
|Ambulating | | | | | |
|Transfers | | | | | |
|Meal prep | | | | | |
|Shopping | | | | | |
| | | | | | |
Refer to Self- Medication Assessment for skills specific to that process
|Other information related to ADL skills: | |
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|Name: | |DDS # | |
|Indicate identified bathing risks: None identified | |
| |
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|Indicate identified ambulation/ fall risks: None identified | |
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Current Nursing Support: RN LPN None needed
Current Frequency of Nursing Support: 24 hour 1st & 2nd shift daily weekly monthly
| other (specify): | |
|Other Comments: | |
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Part V. Recommended Health Care Plan/ Strategy
|Health Needs |The Plan: |RN Monitoring , Nursing |Training needs |
|To be addressed |How to and Who will address |Support & Frequency |Individual/ Staff |
| | | | |
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|Name: | |DDS # | |
Part V. Recommended Health Care Plan/ Strategy (continued)
|Health Needs |The Plan: |RN Monitoring , Nursing |Training needs |
|To be addressed |How to and Who will address |Support & Frequency |Individual/ Staff |
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RN Reassessment recommended: month(s) year (s) as needed other
|Reassessment tool to be used: | |
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Signature of RN Completing Assessment Print Name
| | | |
Region/ Agency Date
Distribution: Individual’s file, Evaluating RN, Copies as appropriate
|If this form is used for the transfer of information, complete below and retain copy at previous placement |
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| | | | | | | |
| Signature of Receiving RN | |Date | |Region/Agency |
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