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: |      |

|      |

|      |

|      |

|      |

|      |

|Advance Directives/DNR: |      | None |

|Seizure Disorder: NA Type: |      |Frequency: |      | VNS |

|History of Illnesses/ Injuries/ Hospitalizations (recent): |      |

|      |

|      |

|      |

|      |

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 |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

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

|      |

|      |

|Bed Side Rails use: (specify type and frequency) |      |

| |

| 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: |      |

| |      |

| |      |

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: |      |

|      |

|Name: | |DDS # | |

|Indicate identified bathing risks: None identified |      |

| |

| |

|Indicate identified ambulation/ fall risks: None identified |      |

| |

Current Nursing Support: RN LPN None needed

Current Frequency of Nursing Support: 24 hour 1st & 2nd shift daily weekly monthly

| other (specify): |      |

|Other Comments: |      |

|      |

|      |

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 |

| | | | |

|      |      |      |      |

|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 |

| | | | |

|      |      |      |      |

RN Reassessment recommended:       month(s)       year (s) as needed other

|Reassessment tool to be used: |      |

|      | |      |

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 |

| |

| |      | |      | |      | |

| Signature of Receiving RN | |Date | |Region/Agency |

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