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NURSING SERVICES ASSESSMENT DATE OF VISIT DATE OF LAST VISIT DATE

By Melvin Perkins,2014-05-12 17:01
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NURSING SERVICES ASSESSMENT DATE OF VISIT DATE OF LAST VISIT DATE

     DATE OF VISIT DATE OF LAST VISIT DATE OF CARE

    NURSING SERVICES

    CASE MANAGER’S NAME ASSESSMENT

    I. GENERAL INFORMATION

    A. CLIENT INFORMATION AND HOUSING ARRANGEMENT

    CLIENT’S NAME DATE OF BIRTH AGE CLIENT ID GENDER

     Male

    Female ADDRESS CITY STATE ZIP CODE

    RESIDENCE TYPE

     Parent Home Own Home (own, lease, rent from non-provider)

     Relative Home Adult Family Home

     Provider’s Home Adult Residential Center

     Current and correct on CARE

     New Information:

B. SIGNIFICANT OTHER INFORMATION

    NAME TELEPHONE NUMBER (INCLUDE AREA CODE)

    ADDRESS CITY STATE ZIP CODE

    RELATIONSHIP TO CLIENT

     Legal Representative: Full Legal Guardian Partial Legal Guardian Power of Attorney

     Parent: No Guardianship Full Legal Guardian Partial Legal Guardian Power of Attorney

     Other Relative/No Legal Relationship

     Other/No Legal Relationship

     Current and correct on CARE

     New Information:

C. ASSESSMENT PARTICIPANTS

    ASSESSMENT PARTICIPANTS

     TELEPHONE NUMBER NAME (Include area code)

D. EMERGENCY CONTACT INFORMATION

     Current and correct on CARE

     New Information:

DSHS 13-784 (REV. 02/2007)

    E. DEMOGRAPHIC AND LANGUAGE INFORMATION

     Current and correct on CARE

     New Information:

    II. HEALTH STATUS A. HEALTHCARE PROFESSIONALS

    TREATING PROVIDER’S NAME DATE LAST SEEN

REASON

FINDINGS

TREATMENT/PRESCRIPTIONS

OTHER TREATING PROVIDER’S NAME DATE LAST SEEN

REASON

FINDINGS

TREATMENT/PRESCRIPTIONS

B. DIAGNOSES

    LIST

     Current and correct on CARE

     New Information:

     Concerns:

C. MEDICATIONS AND ASISTANCE REQUIRED

     Current and correct on CARE

     New Information:

     Provider is working within their scope of practice

     Nurse Delegation needed

     Recommendations:

DSHS 13-784 (REV. 02/2007) 2

D. BLADDER CONTROL, APPLIANCES, PROGRAM, AND MANAGEMENT

     Current and correct on CARE

     New Information:

     Concerns:

     Recommendations:

E. BOWEL CONTROL, APPLIANCES, PROGRAM, AND MANAGEMENT

     Current and correct on CARE

     New Information:

     Concerns:

     Recommendations:

    F. OTHER HEALTH INDICATORS Speech, sight, hearing

     Current and correct on CARE

     New Information:

     Recommendations:

    Tobacco use, substance abuse

     Current and correct on CARE

     New Information:

     Recommendations:

Allergies

     Current and correct on CARE

     New Information:

     Recommendations:

Special diet

     Current and correct on CARE

     New Information:

     Recommendations:

DSHS 13-784 (REV. 02/2007) 3

Nutrition, height, and weight

     Current and correct on CARE

     New Information:

     Concerns:

     Recommendations:

DSHS 13-784 (REV. 02/2007) 4

G. HEALTH INDICATORS RELATED TO THE HOUSEHOLD ENVIRONMENT

    NOTE: Assessor is not expected to do a household inspection but is reporting on what is observed during visit. Suspicion of abuse of neglect requires a referral to APS (in-home), CRU (licensed facilities) or CPS.

Observations of conditions that place the client’s health at risk:

    DSHS 13-784 (REV. 02/2007) 5

    III. SKIN CARE ISSUES A. SKIN PROBLEMS WITHIN THE LAST 14 DAYS (SKIN TEARS, RASH, BRUISES, WOUND CARE, PRESSURE ULCERS)

     Yes No

    Risk indicators for skin breakdown related to pressure exist:

     Incontinent of bladder or bowel

     Wheelchair dependent

     Quadriplegia

     Paraplegia

     Bedfast

     Diabetic

     Cognitive Impairment (CPS>3)

     Other:

If any of the skin observation protocol risk indicators exist initiate the skin observation protocol.

    Skin observation protocol initiated: Yes No If yes:

    What was done?

What was found?

What action was taken?

What follow-up is needed?

    Other skin care needs not related to the skin observation protocol:

     Recommendations:

B. TREATMENTS AND THERAPIES

     Current and correct on CARE

     New Information:

     Concerns:

     Recommendations:

DSHS 13-784 (REV. 02/2007) 6

    C. SELF-CARE TRAINING NEEDS

     Current and correct on CARE

     New Information:

     Concerns:

     Recommendations:

    IV. MOODS AND BEHAVIORS

    A. Impaired judgment, hallucinations, delusions, aphasia, verbally abusive, depression, withdrawn, assaultive, danger to

     self, other behavior impairments:

     Current and correct on CARE

     New Information:

     Concerns:

     Recommendations:

B. Accuses, rummages, takes belongings, sexual issues, exposes self, disrobes in public, combative during care,

     screaming:

     Current and correct on CARE

     New Information:

     Concerns:

     Recommendations:

C. Wandering

     Current and correct on CARE

     New Information:

     Concerns:

     Recommendations:

D. Short Term Memory

     Current and correct on CARE

     New Information:

     Concerns:

DSHS 13-784 (REV. 02/2007) 7

     Recommendations:

E. Long Term Memory and Orientation

     Current and correct on CARE

     New Information:

     Concerns:

     Recommendations:

F. Anxiety Issues

     Current and correct on CARE

     New Information:

     Concerns:

     Recommendations:

    V. PERSONAL CARE NEEDS

    A. Functional ADLS

     Current and correct on CARE

     New Information:

     Concerns:

     Recommendations:

B. Supervision Needs

     Current and correct on CARE

     New Information:

     Concerns:

     Recommendations:

    VI. CAREGIVER INFORMATION

    A. Caregiver Information

     Current and correct on CA

     New Information:

DSHS 13-784 (REV. 02/2007) 8

     Concerns:

     Recommendations:

B. Provider Issues

    Service provided by: Individual provider Homecare agency AFH BH

    Number of IPs providing service:

Training (applicable to IPs only):

     Training needs assessed. Provider name:

     If serving an adult, the IP has completed the required training.

     IP has not completed required training.

     Training provided by RN to (Name of Provider)

     Describe training:

     Training recommendations for

     Describe recommendations:

Performance:

     No concerns regarding caregiver performance

     I have the following concerns regarding caregiver performance:

DSHS 13-784 (REV. 02/2007) 9

    This Summary Report is to become Page One of the completed document

    VI. CAREGIVER INFORMATION

     No concerns. No change required in client care plan.

     Immediate actions taken by nurse:

    Describe issue and action taken:

Persons/agencies notified:

     Response required of case resource manager

     Recommended changes to the assessment and/or service plan based on new information entered into the following

     assessment section of this form:

     Client information or demographics

     Client living situation

     Significant other information

     Health Status (diagnosis, bowel and bladder control, med assistance, other)

     Health risks in environment

     Skin care issues

     Treatments and therapies

     Moods and behaviors

     Wandering

     Memory and orientation

     Anxiety issue

     Plan of care supervision and caregiver information

     Functional ADLS

     Supervision needs

     Provider issues

Recommendations for additional nursing service activities:

    Approximate date of next RN visit:

    APS/CPS must be notified of suspicion of abuse, neglect, or exploitation. Call 1-866-363-4273 (1-866-ENDHARM). My signature indicates that I have assessed the above client. To the best of my knowledge, the information contained on

    this assessment is true and correct.

    NURSE’S SIGNATURE DATE

    Distribution:

    Date sent: DDD

     Family member/guardian (by request) Date sent: CRM RESPONSE TO RN RECOMMENDATIONS

     See addendum for additional documentation. CMR’S SIGNATURE DATE

DSHS 13-784 (REV. 02/2007) 10

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