SG Safety Goal
#
COMPREHENSIVE ADULT SOC ASSESSMENT
Clear Form
WITH CMS 485 (POC) INFORMATION
POC (CMS - 485) Box
PT ID PERFORMED VIA NAME, DOB, FACE RECOGNITION AND ADDRESS BEFORE SERVICE PROVIDED SG
/
/
2
(M0030) Start of Care Date:
Certification Period:
From __/___/
year
month day
3
To
/
Provider Number:
Physician name: _______________________________
Phone:
Employee's Name/Title Completing the Assessment:
Address:
___________________________ 24
_________________________________________
Phone Number: ______________________________
/
Date last visited:
/
Other Physician (if any): _______________________________
___________________________
_________________________________________
Phone Number: ______________________________
Referral date:
/
_____________________________________________________________
/
Reason:
/
Patient ID Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __
(Medical Record)
Address:
6
Patient Name:____________________________________________
Address: _____________________________________________________
/
..
6
_____________________________________________________
..
m
ALF / AFHC (circle)
.c
o
Social Security Number:_________________ Name:
Fax:
1
Phone:
Medicaid Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __
EMERGENCY CONTACT:
Address:
Phone:
Birth Date: __ __ /__ __ /__ __ __ __ Gender:
8
month / day / year
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Relationship:
RECENT HOSPITALIZATION?
OTHER:
1
Female 9
Male
-
Yes, dates
No
Reason:
SA
Evacuation Form needed? Emergency Registration Completed (please document)
CHIEF COMPLAINT:
PREVIOUS OUTCOMES:
40
Surgeries:
30
5.
Open Wound
81
8.
59
PERTINENT HISTORY AND/OR PREVIOUS OUTCOMES: Diabetes
Respiratory
Osteoporosis
Hypertension
Cardiac
Insulin Dependent
Fractures: _______
Non Insulin Dependent
Cancer (site:
)
Other:
New diagnosis/condition?
IMMUNIZATIONS:
Needs:
Influenza
Infection
Primary & Other Diagnosis
Temperature:
Oral
Rectal
Yes, specify
H1N1
Tetanus
Pneumonia
Sitting/lying R
L
Blood Pressure:
Standing R
Pulse:
Apnea periods -sec.
Irregular
ICD-9-CM
12
Rest
Apical
Radial
Regular
Activity
Cheynes Stokes
Brachial
Carotid
Irregular
Accessory muscles used
12
)
(
)
(
Date
/
/
Date
/
/
(
)
Date
/
/
(
)
Date
/
/
(
)
Date
/
/
)
Date
/
/
(
)
Date
/
/
(
)
Date
/
/
(
Surgical Procedure
Other (specify)
L
Axillary
Tympanic
Respirations:
Death rattle
Regular
No
Up-to-date
VITAL SIGNS:
PRESENT ILLNESS/DIAGNOSIS:
DIAGNOSIS:
st
em
Emergency/Disaster Plan Classification Code:
Immunosuppressed
4
...
Patient Phone: __________________________
Phone:
/
Agency Name:________________________________________ 7
5
REFERRAL SOURCE (if not from Primary Physician):
N/A
/
DATE
/
PHYSICIAN: Date last contacted:
TIME OUT
TIME IN
ICD-9-CM
12
12
Med. Record #
PATIENT NAME - Last, First, Middle Initial
Page 1 of 8
www.pnsystem.com 305.777.5580
SOC ADULT ASSESSMENT
COMPREHENSIVE ADULT SOC ASSESSMENT
1- Poor
3-Fair
2- Guarded
WITH CMS 485 (POC) INFORMATION
20
PROGNOSIS:
5-Excellent
4 Good
Chest pain:
Anginal
Postural
Localized
Substernal
Vise-like
Sharp
Dull
Ache
Radiating
Associated with:
Activity
SOB
Sweats
Jaundice
Frequency/duration
Ptosis
Other (specify)
Palpitations: Nocturnal/Persistent/intermittent
Other (specify)
/
/
Heart rate:
Regular
Irregular
Reg./Irreg.
Orthostatic hypotension
Syncope
Vertigo
NO PROBLEM
BP8 (specify)
Reg.
Irreg. (specify)
Heart sounds:
Hearing aid: R/L
Pulse deficit (specify)
Dependent:
Edema:
Pedal R/L
Non-pitting (site)
Pitting +1/+2/+3/+4
NO PROBLEM
Claudication: R calf/L calf/Night changes
Fatigue
JVD
EARS
EARS
EYES
VISION
SYSTEM REVIEW
Glasses
Contacts: R / L
Prosthesis: R / L
Infections
Cataract surgery: Site
Other (specify, incl. hx)
Glaucoma
Blurred vision
Legally blind
HOH: R / L
Vertigo
Other (specify, incl. hx)
Deaf: R / L
Tinnitus
CARDIOVASCULAR
STATUS
CARDIOVASCULAR
Date
HEAD/NECK
Headache( see Neurological section)
Injuries/Wounds ( see Skin Condition/Wound section)
Masses/Nodes: Site
Size
Alopecia
Other (specify, incl. hx)
NO PROBLEM
Type
/
.c
o
m
Dysphagia
Hoarseness
Lesions
Sore throat
Other (specify, incl. hx)
THROAT
Congestion
Epistaxis
Sinus prob.
Loss of smell
Nose surgery:
Other (specify, incl. hx)
Rx
NO PROBLEM
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RESPIRATORY STATUS
Clear
Crackles
Wheeze
Absent
NO PROBLEM
NO PROBLEM Breath sounds:
Cough: Dry/Acute/Chronic
Dentures: Upper /Lower /Partial
Masses/Tumors
Productive: Thick/Thin/Difficult Color
Gingivitis
Ulcerations
Toothache
Smoker:
packs/day X
years
Any mouth surgery/procedure:
Exertion: amb. feet
Dyspnea:
Rest
during ADLs
Other (specify, incl. hx)
NO PROBLEM
Orthopnea: # of pillows
ENDOCRINE
Crepitus/ Fremitus: Location
Hemoptysis: Frequency
Amt.
Enlarged thyroid
Fatigue
Intolerance to heat/cold
Diabetes: Type I/Type II Onset
Barrel chest
/
/
Skin temp/color change Percussion: Resonant/Tympanic/Dull
mos.
years
Diet/Oral control X
R
Lat.
Ant.
Post.
Chart lobe:
L;
Med./dose/freq.
Insulin/dose/freq.
02 Sat.
Hyperglycemia: Glycosuria / Polyuria / Polydipsia
Mask
Nasal
Trach
02 use:
L/rnin. by
Hypoglycemia: Sweats/Polyphagia/Weak/Faint/Stupor
Liquid
Concentrator
Gas
Blood Sugar Range
Oxygen Precaution/Fire Prevention followed/explained to patient SG
Self-care/Self-observational tasks (specify)
Other (specify, incl. hx)
Other (specify, incl. hx)
81
8.
59
40
SA
MOUTH
MOUTH
NOSE
NOSE
NOSE/THROAT/MOUTH
Thrombus: Site
Cramps: LE/UE/Night (site)
Cyanosis (site)
Cap refill: <3 sec./ >3 sec.
Pulses: LDP/LPT/RDP/RPT
Pacemaker: Date
/
Other (specify incl. hx)
4-Hearing
30
5.
FUNCTIONAL LIMITATIONS
1 -Amputation
2-Bowel/Bladder
(incontinence)
3 - Contracture
B- Other (specify)
Generalized Weakness
Arthralgia
Dizziness
Headache
Insomnia
Anxiety
SOB on exertion
Poor vision
7-Ambulation
5-Paralysis
NO PROBLEM
NO PROBLEM
HOMEBOUND REASON:
18A
(Mark all that apply):
Medical restrictions
Needs assist of 1-2 persons
Unsteady Gait
Needs assistance for all activities (ADL's)
Dependent upon adaptive device(s)
Generalized Weakness
Requires assistance to ambulate/Decreased Range of Motion
Confusion, unable to go out of home alone
Unable to safely leave home without assistance
18A
A -Dyspnea with
8-Speech
6-Endurance
9-Legally blind
Legs weak
Productive cough
Back Pain
Heartburn
Decreased Bil. breath sounds
Pain on ambulation
Palpitations
Unsteady Gait
Limited Mobility
Varicositis on lower ext.
Limited ROM
Edema in __________
Leg cramps
Chest pain on exertion
Freq. Coughing episodes
Fatigues at times
Needs assistance of 1 person
Mobility/Ambulatory device(s) used:
Severe SOB, SOB upon exertion, amb. ____ feet
Bedbound (Partial/Complete)
Other (specify):
GENITOURINARY STATUS
(Check all that apply:)
Incontinence: Urinary
Burning/pain
Color:
Odor:
Amber
Yellow/straw
Yes
No
Inflated balloon with
Hesitancy
Hematuria
Oliguria/anuria
Bowel
mL
Patient tolerated procedure well
Nocturia x
Urgency/frequency
Diapers/other:
Brown/gray
Blood-tinged
Other:
Clarity:
Urinary Catheter: Type
Last changed on:
without difficulty
Suprapubic Irrigation solution: Type (specify):
Yes
No
Clear
Cloudy
Sediment/mucous
with
Foley inserted (date)
Amount
mL Frequency
French
Returns
Urostomy (describe skin around stoma):
PATIENT/CLIENT NAME - Last, First, Middle Initial
Med. Record #
Page 2 of 8
www.pnsystem.com 305.777.5580 ADULT SOC ASSESSMENT
NUTRITIONAL STATUS
1800 cal ADA
amt.
3-Up as tolerated
4-Transfer bed/chair
5-Exercises prescribed
amt.
Restrict fluids
Good
Fair
Vomiting: Frequency:
Amount:
Excellent
Anorexic
Poor
7-Independent in home
LIVING ARRANGEMENTS/CAREGIVER INFORMATION
NUTRITION HEALTH SCREEN
Directions: Circle each area with ''yes'' to assessment, then total score
to determine additional risk.
YES
Has an illness or condition that changed the kind and/or amount of
food eaten.
Eats fewer than 2 meals per day.
2
3
2
Eats few fruits, vegetables or milk products.
Has 3 or more drinks of beer, liquor or wine almost every day.
Has tooth or mouth problems that make it hard to eat.
Does not always have enough money to buy the food needed.
Eats alone most of the time.
Takes 3 or more different prescribed or over-the-counter drugs a day.
Without wanting to, has lost or gained 1 0 pounds in the last 6 months.
Not always physically able to shop, cook and/or feed self.
TOTAL
2
2
4
1
1
2
2
INTERPRETATION
House
New environment
Apartment
Family present
Lives alone
Lives w/others:
Primary caregiver (name)
Relationship/Health status
Assists with ADLs
Provides physical care
Other (specify)
Secondary/Other caregivers (describe)
GENITALIA
Discharge/Drainage: Urine/Vag. mucus/Feces
Lesions/Blisters/Masses/Cysts
Inflammation
Prostate problem: BPH/TURP Date
/
Self-testicular exam Freq.
Menopause:
Hysterectomy
Date
/
Date last PAP
Results
/
/
Breast self-exam. freq.
Mastectomy: R/L Date
/
/
Other (specify incl. hx)
0-2 Good. As appropriate reassess and/or provide information based on situation.
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3-5 Moderate risk. Educate, refer, monitor and reevaluate based on patient
situation and organization policy.
6 or > High risk. Coordinate with physician, dietitian, social service professional
or nurse about how to improve nutritional health. Reassess nutritional status and
educate based on plan of care.
NO PROBLEM
SA
Reprinted with permission by the Nutrition Screening Initiative, a project of the American Academy of
Family Physicians, the American Dietetic Association and the National Council on the Aging, Inc., and
funded in part by a grant from Ross products Division, Abbott Laboratories Inc.
ELIMINATION STATUS
30
5.
81
8.
59
40
Usual frequency
Last BM
/
/
>3x/day
<3x/day
Diarrhea: Black / watery / Sanguineous
Mucus/Pain/Foul odor/Frothy Amount
Abnormal stools: Gray/Tarry/Fresh blood
Constipation: Chronic/Acute/Occasional
Freq.
Lax./Enema use: Type
Hemorrhoids: Internal/External/Painful
Rx (specify)
Flatulence: Freq.
Incontinence of stool: Freq.
Impaction
Abdominal distention: Cramping/Pain Freq.
inches
Ascites: Girth
Firm/Tender X
quads
quads
Bowel sounds: Active/Hyperactive X
quads
Absent X
Rebound/Hot/Red/Discolored
Colostomy: Sigmoid/Transverse Date
/
/
NO PROBLEM
PSYCHOSOCIAL
Surgical alteration
/
/
Discharge: R/L
NO PROBLEM
HEMATOLOGY/ IMMUNE
Secondary Bleed: GI/GU/GYN/Unknown
Anemia: Iron deficient/Pernicious
Thrombocytopenia
Ablastic/Hemolytic/Polycythemias
Coagulation disorders
Hemophilia, other
Malignancies (specify):
Prior Rx
Complications
Other (specify, immunological problem)
NO PROBLEM
NEUROLOGICAL
Oriented X
Insomnia/Change in sleep pattern
Vertigo
Ataxia
Slurred speech
Syncope
Sensory loss
Numbness
Impaired decision-making ability
Hx of frequent falls
Memory loss: Short term/Long term
Headache: Loc.
Freq.
Aphasia: Receptive/Expressive
Motor change: Fine/Gross
Weakness: UE/LE Location
Tremors: Fine/Gross/Paralysis
Stuporous/HalIucinations: Visual/Auditory
Unequal pupils: R/UPERRLA
Hand grips: Equal/Unequal, specify
Strong/Weak, specify
Psychotropic drug use (specify)
Dose/Freq.
Other (specify, incl. hx)
NO PROBLEM
Depressed: Recent/Long term Fix
Creole
Primary language: English Spanish
Russian
Language barrier Needs interpreter
Learning barrier: Mental/Psychosocial/Physical/FunctionaI
Able to read/write Educational level
Spiritual/Cultural implications that impact care.
Spiritual resource
Phone No.
Angry
Flat affect
Discouraged
Suicidal: Ideation /Verbalized
Withdrawn
Disorganized
Difficulty coping
Substance use: Drugs/Alcohol/Tobacco
PATIENT/CLIENT NAME - Last, First, Middle Initial
CMS 485 (POC): 18B
C-No restrictions
D-Other (specify)
6-Partial weight bearing
Heartburn (food intolerance): Frequency:
Other:
Plan
8-Crutches
9-Cane
A-Wheelchair
B-Walker
m
Nausea
NPO
Low cholesterol Other:
Increase fluids:
Appetite:
NAS
.c
o
Low Fat
Low Sodium
1 -Complete bedrest
2-Bedrest/BRP
st
em
2 gm Sodium
ACTIVITIES PERMITTED
Controlled Carbohydrate
16 DIET, Nutritional requirements:
Due to: Lack of motivation
Inability to recognize problems
Denial of problems
Other, specify
Unrealistic expectations
Inappropriate responses to caregivers/clinician
Invested in ''sick role''
Inappropriate follow-through in past
Verbal/Emotional
Actual
Evidence of abuse: Potential
Financial
Physical
MENTAL STATUS: 19
5 - Disoriented
3 - Forgetful
7 - Agitated
1 - Oriented
4 - Depressed
2 - Comatose
6 - Lethargic
8 - Other:
NO PROBLEM
Alert
Irritable
Anxious
Forgetful at times
ID#
Page 3 of 8
www.pnsystem.com 305.777.5580 SOC ADULT ASSESSMENT
SAFETY MEASURES
Safety Measures: CMS485 (POC)
Cast Precautions
Change position slowly
Coumadin/Heparin Precautions
Do not lift, bend, stoop
Good handwashing technique
Oxygen Precaution/Fire prevention SG
Practice Universal Precautions
Prev. Infection Complications
15
Respiratory Precautions
Diabetic Precautions
Wound/Decubitus precautions
Adequate lighting
Prevent Cardiac Overload
Prevent Falls and Injuries SG
Safe Ambulation
Safe Transfers
Clear pathways
SAN Precautions
Correct handwashing technique SG
Catheter Care
Check bathroom, floor/stairs for safety hazards
Provide Emotional Support
Other:
Emergency Plan
Oxygen: HME Co.
Cardiac Precautions
Maintain Safe/clear Environment Phone:
Maintain Good Skin care
Fire Alarm
Smoke Alarm
Seizure Precautions
Suicide precautions
Support due functional limitation
Teach coping skills
Safe storage/disposal syringes
G.I. Precautions
G.U. Precautions
PAIN MANAGEMENT
SKIN CONDITION/WOUNDS/LESION
Itch Rash
Decubitus
Dry Scaling Incision Wounds Lesions
Fistulas Abrasions Lacerations Sutures
Bruises Ecchymosis
Turgor: Good
Poor
Pallor:
Edema:
Other (specify, incl. pertinent hx)
Staples
Origin:
Location
Onset
Jaundice
Redness
Present Pain Management Regimen
NO PROBLEM
Lymph Hema.
Effectiveness
Other (specify)
m
Denote location of specific skin conditions/wounds by numbering
appropriately on illustrations below.
st
em
.c
o
Quality (i.e., burning, dull ache)
Intensity level: 0 1 2 3 4 5 6 7 8 9 10
Freq./Duration
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Aggravating/Relieving Factors:
Pain Management History
SA
Patient is prone to FALL:
#I
CONDITION
#2
HOME ENVIRONMENT SAFETY
#4
#3
Safety hazards in the home: (check all that apply)
Y
SG Fire alarm/smoke detector /Fire extinguish
Y
Inadequate heating/ cooling/ electricity / lighting
8.
59
40
Size (cm)
Depth
Stage
No
Yes:
Fall risk assessment conducted every_______________ NO PROBLEM
Fall prevention program in place, patient instructed SG
Comment:
Drainage/Amt.
Tunneling
81
Odor
Sur. Tis.
30
5.
Edema
Stoma
ALLERGIES
None known / NKA
Penicillin
Iodine
Aspirin
Eggs
Sulfa
Animal dander and urine
Pollens and mold spores
Insect bites
17
Dairy/Milk products
Dust mites
Other
MUSCULOSKELETAL
Fracture (location)
Swollen, painful joints (specify)
Location
Contractures: Joint
Poor conditioning
Atrophy
Decreased ROM
Paresthesia
Shuffling/Wide-based gait
Weakness
Amputation: BK/AK/UE; R/L (specify)
Paraplegia
Quadriplegia
Hemiplegia
Other (specify, incl. pertinent hx)
Walker
APPLIANCES/AIDS/SPECIAL EQUIPMENT: Cane
Wheelchair
Crutch(es) Lifts
Bedside Commode Prosthesis:
Other (specify):
Hospital bed
N
N
Hurricane, Disaster Emergency supplies/kits
Y
N
First aid box/Emergency Equipment or Supplies
Y
N
Unsafe gas/electrical appliances or electrical outlets
Y
N
Inadequate running water, plumbing problems
Y
N
Unsafe storage of supplies/ equipment/ HME
N
No telephone available and/or unable to use the phone
Y
Y
Pest problems, Insects/rodents
Y
N
Medications stored safely, clearly-easy use
Y
N
Emergency planning, Exit Plan in place, more than one exit
Y
N
Enough Ventilation
Y
N
N
Safe Beds/Chairs, clear pathways
Y
N
Able to follow directions in case of Emergency
Y
N
Slippery Floors, Ashtrays (if a smoker)
Y
N
Plan for power failure, emergency lights, flashlights, etc.
Relevant medical appliances, if applicable ( wheelchair, O2, Monitors, etc.)
Hurricane Shutter , Disaster Plan
Y
Y
Y
N
N
N
ENTERAL FEEDINGS - ACCESS DEVICE - IV
TPN
Device:
Nasogastric
Gastrostomy
Jejunostomy
IV:
Pump: (type/specify)
Feeding type:
Bolus
Financial ability to pay for medications/insurance covered:
Comment:
Yes
Continuous
No
N/A
Med. Record #
PATIENT/CLIENT NAME - Last, First, Middle Initial
Page 4 of 8
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ADULT SOC ASSESSMENT
PATIENT CARE COORDINATION
CARE PLAN: Reviewed with patient involvement CARE COORDINATION:
MEDICATION RECORD: Medication Form completed/reviewed/updated 10
Physician
SN
No change
PT
OT ST
MSW
Aide
Other (specify):
Order obtained
Significant side effects
SG Medication Management, Check all that applies/identified:
Potential adverse effects/drug reactions
Ineffective drug therapy
Significant drug interactions
Duplicate drug therapy
Non-compliance with drug orders
Explain:
Expected Outcome:
Patient unable to perform own Wound Care due to
Patient unable to Insuline/Injection self administration due to
No S/O or C/G able/willing for wound care/Insulin-Injection administration at this time:
DME SUPPLIES
2x2's
IV start kit
4x4's
ABD's
Cotton tipped applicators
Wound cleanser
Wound gel
Drain sponges
Gloves:
Bathbench
IV pole
Syringes
Cane
IV tubing
Commode
Alcohol swabs
Urinary bag/pouch
COTTON TIP APP
DUODERM CFG
Angiocatheter size
Ostomy pouch (brand, size)
HY-TAPE 2''
External catheters
Peroxide
Ostomy wafer (brand, size)
Extension tubings
Central line dressing
Stoma adhesive tape
Infusion pump
Batteries size
Kerlix size
Syringes size
Transparent dressings
Leg Straps Cath
Hospital bed
Hoyer lift
Enteral feeding pump
Nebulizer
Oxygen concentrator
Enema supplies
Feeding tube:
Suction machine
Ventilator
type
size
Suture removal kit
M
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N
Sy
Duoderm
Eggcrate
SYRINGES
FOLEY/CATH SUPPLIES:
Fr catheter kit
(tray, bag, foley)
Pressure relieving device
INSULIN SYRINGE ____ CC
Glucometer
Straight catheter
Betadine Solution
Irrigation tray
Ace band size
Saline/NSS
Thermometer
MEFIX 2X11 YD (EA)
Acetic acid
Red Box (Biohazard)
MICROPORE TAPE 2"
Sharp Container
SOFTWICK 4X4
Texas Cath
SA
Other
Quad Cane
Special mattress overlay
INSERTION TRAY 5CC
Skin protectant
Nu-gauze
Colostomy Supplies
Side Rails
Chemstrips
Sterile
Non-sterile
Hydrocolloids
Ointment
ALCOHOL PREP PADS
m
Telfa
Tape
Abd Pads
Underpads, size:
.c
o
14
Injection caps
st
em
Saline/NSS
Walker
Wheelchair
Staple removal kit
Steri strips
Tens unit
TRIPLE ANTIBIOTIC 30GR
Other
VASELINE GAUZE 3X9
KLING 4
PATIENT OTHER EVALUATIONS
No
No
No
No
No
No
No
No
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Patient/CG able to understand instructions/teaching:
Comment(s):
21
40
81
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
30
5.
Wound/Decubitus care:
Diabetic management/care:
Insulin administration:
Glucometer use/calibration:
Nutritional management/Diet:
Trach care:
Ostomy care:
Foley care:
Medication management: Administration: Oral
Injection
Physician follow up visits/appointments maintained:
Oxygen use/precautions maintained, fire prevention: SG
Use of home medical equipment / devices:
Pain Management / Home prescribed exercises:
Elimination, Incontinence management: ___________________
8.
59
Check all that applies:
Patient/caregiver(CG) independent with:
Yes
Inhaled
IV-Infused
Yes
Yes
Yes
Yes
Yes
N/A
N/A
N/A
N/A
N/A
No
No
No
No
No
Does the patient/CG have a plan when disease symptoms exacerbate
Yes
No
(e.g., when to call the nurse / Agency vs. emergency 911):
Pshycological care / behaviour problems prevention
Caregiver/Family member present during the visit:
No Explain:
Yes
No
N/A
NEEDS FURTHER TEACHING
Orders by discipline (optional) To complete CMS485 (POC)
SN - ORDERS - FREQUENCY/DURATION:
SKILLED OBSERVATION/EVALUATION ASSESS VITAL SINGS & S/S COMPLICATIONS:
INSTRUCT/EVALUATE UNDERSTANDING OF DISEASE PROCESS
DETECTING COMPLICATIONS
DIET/NUTRITIONAL STATUS SAFETY PRECAUTION/EMERGENCY MEASURES, MED-REGIMEN
General
PT - ORDERS - FREQUENCY/DURATION:
OT - ORDERS - FREQUENCY/DURATION:
ST - ORDERS - FREQUENCY/DURATION:
OTHER - ORDERS - FREQUENCY/DURATION:
PATIENT/CLIENT NAME - Last, First, Middle Initial
Med. Record #
Page 5 of 8
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ADULT SOC ASSESSMENT
If the patient experiment:
-ADL/IADL Deficit - Elimination Deficit - Impaired Mobility:
Indications for Home Health Aide may be needed:
MD Order obtained:
Yes
No
Patient/Family:
AIDE - ORDERS - FREQUENCY/DURATION:
21
Refused
N/A (Home Health Aide Services not needed)
Other Services ordered:
SN
MSW
OT
PT
ASSIST WITH PERSONAL CARE AND ADL'S
TPR
REPORT SIGNIFICANT FINDING TO AGENCY/CASE MANAGER
OTHER:
ST
Comment:
ACTIVITIES OF DAILY LIVING
(Legend: I-Independent; A-Assist; D-Dependent)
COMMENTS
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Instructions/Information Provided (Check all that apply):
RETURN TO INDEPENDENT AMBULATION. BE SAFE IN SELF CARE.
SA
PATIENT WILL BE ABLE TO FUNCTION WITH ASSISTANCE OF CAREGIVER
WITHIN HIS/HER CURRENT LIMITATIONS AT HOME.
GOOD/FAIR RETURN TO PREVIOUS LEVEL OF ADLS INDEPENDENTLY.
PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HIS/HER CURRENT LIMITATIONS AT HOME.
OTHER:
40
DISCHARGE PLANS
8.
59
WILL DISCHARGE THE PATIENT WITHIN ____ WEEKS, WHEN PATIENT AND/OR
No
REHAB POTENTIAL LEVEL:
30
5.
Yes
81
2. CAREGIVER IS/ARE ABLE TO DEMONSTRATE PROPER CARE MANAGEMENT, NO S/S COMPLICATIONS.
PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HIS/HER CURRENT LIMITATION AT HOME.
3.
4. OTHER:
Discussed with patient/client?
(who assists, assistive device used, etc.)
m
I
ACTIVITY
PRIOR Level of Function
Eating/Kitchen access
Transfer abilities
Dressing/Grooming
Bathing/ Personal Care
Toileting/Hygiene abilities
Ambulation/ROM
Communication (verbal, non-verbal)
Preparing/Serving light meals
Preparing full meals
Light housekeeping
Personal laundry
Handling money
Using telephone
Reading, Writing
Hair care, Skin Care
Managing Medications
Other (Specify)
G O A L S
22
WASH CLOTHES
LIGHT HOUSEKEEPING
ASSIST TO DRESS
PERI CARE
TUB/SHOWER BATH
PERSONAL CARE
HAIR COMB
ORAL HYGIENE
Patient Rights and responsibilities
Do not resuscitate (DNR) (if applicable)
State hotline/ABUSE number
Service Agreement/Contract
Advance directives information
OASIS/HIPAA Privacy Notice, Confidentiality
Emergency Plan, classification, instructions
Agency phone numbers, address
Medication sheet, instructions
Home safety guidelines
Client Information Handbook
Alzheimer's, Fall prevention, Sensory impairments info
Grievance Procedures
Pain Management info
Standard precautions /handwashing/ Infection Control
Admission criteria, Information for Home visit, Services, Frequency
Diabetes Control, other disease management information
Care Plans
Mission, ownership information
Local Resources Guide
Other
SKILLED INTERVENTION/SERVICE
Foley Change/Care
Wound Care / Dressing Change
Patient Education/teaching
Prep. / Admin. Insulin
Diabetic Observation / Care
Procedure/Tx well
tolerated by Pt.
Aseptic Tech. Used.
Sharps Discarded Inside Sharps Container
Standard/Universal Precautions Followed
Quality Control of Glucometer Performed
No
caregiver/family
available/willing
to
help
patient
with
care, procedures.
Management/Evaluation Patient's Care Plan
Correct handwashing technique followed SG
Skilled Observation / Assessment
INJECTION ROUTE:_______ SITE: _____ MED. GIVEN: ______________________ DOSE: __________ REACTION: _____________________________
DRUG REGIMEN REVIEW COMPLETED/RECONCILIATED?
PATIENT/CLIENT/CAREGIVER RESPONSE
No
Yes
I
SUMMARY CHECKLIST
AIDE CARE PLAN COMPLETED, REVIEWED, EXPLAINED TO AIDE
N/A
Frequency of Supervision: ___________ Authorization obtained from Patient/CG
N/A
If needed, Branden, Flac, Timed Get Up scale/test were completed?
Yes
No
PATIENT ADMISSION PACKAGE COMPLETED, AGREEMENT EXPLAINED TO PATIENT?
Yes
No
PATIENT/CLIENT NAME - Last, First, Middle Initial
SIGNATURES/DATES
x
/
PatientlClientlCaregiver (optional if weekly is used)
/
Professional signature/title
/
Date
/
Date
Med. Record #
Page 6 of 8
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ADULT SOC ASSESSMENT
Med. Record #
Patient Name:
Orders by discipline (optional) To complete CMS485 (POC)
21
Included as reference only, your Professional Staff must review/update/personalized/approve the orders.
SN - ORDERS - FREQUENCY/DURATION:
SKILLED OBSERVATION/EVALUATION ASSESS VITAL SINGS & S/S COMPLICATIONS:
General INSTRUCT/EVALUATE UNDERSTANDING OF DISEASE PROCESS DETECTING COMPLICATIONS
DIET/NUTRITIONAL STATUS SAFETY PRECAUTION/EMERGENCY MEASURES, MED-REGIMEN
Angina ASSESS FOR CHEST PAIN: TYPE, LOCATION, INTENSITY, DURATION & FREQUENCY I/S PAIN
MANAGEMENT NOTIFY M.D. IF PAIN PERSISTS. I/S GRADUAL PROGRESS ACTIVITY INCREASE
INST. DISCONTINUE ACTIVITY IF CHEST PAIN, DYSPNEA, FATIGUE OR PALPITATIONS OCCUR.
INSTRUCT IN PREPARATION & ADMINISTRATION OF INSULIN INSTRUCT ONSET, PEAK &
Insulin DURATION OF ACTION OF INSULIN INSTRUCT PROPER DISPOSAL OF SYRINGES/NEEDLES
NURSE TO MONITOR BLOOD SUGAR WITH GLUCOMETER OR ___________ON __________FREQUENCY, &
Glucometer NOTIFY M.D. OF ALTERED RESULTS TEACH GLUCOMETER OR __________ PROCEDURE & INTERPRETING RESULTS
Alzheimer's
INST. PREVENTION OF COMPLICATIONS: IE: AVOID OVER-EXERTION, CHILLING, CROWDS, ETC.
INSTRUCT COUGHING, DEEP BREATHING EXERCISES.
INST. PATIENT TO MAINTAIN ADEQUATE REST PATTERN.
INST. PACED ACTIVITY PROGRAM.
EMPHASIZE THE IMPORTANCE OF ADEQUATE DAILY FLUID INTAKE
INSTRUCT PROPER ADMINISTRATION OF OXYGEN THERAPY. INSTRUCT OXYGEN PRECAUTIONS.
INSTRUCT MAINTENANCE OXYGEN EQUIPMENT.
OBSERVE FOR S/S OF DECOMPENSATION SUCH AS INCREASING TACHYCARDIA, W/SUDDEN ONSET, SOB ON MIN.
EXERTION, ORTHOPNEA, EXTREME ANXIETY, PROGRESSIVE CYANOSIS, GENERALIZED PALLOR AND DIAPHORESIS.
SA
Oxygen
CHF
PSYCHOLOGICAL ASSESSMENT ASSESS NEUROLOGICAL STATUS IMPLEMENT AND MONITOR BOWEL REGIMEN &
TEACH PROGRAM TO FAMILY SN TO MONITOR TRANQUILIZER EFFECTS GIVEN FOR SEVERE AGITATION/ANXIETY.
EVALUATE FOR WEIGHT LOSS, WEIGH PATIENT Q VISIT, AND RECORDS WEIGHTS MONITOR LEVEL OF
CONSCIOUSNESS ASSESS COORDINATION AND BALANCE. PROVIDE EMOTIONAL SUPPORT TO PATIENT AND
FAMILY OBSERVATION AND EVALUATION OF BLADDER ELIMINATION HABITS, MANAGEMENT IF INCONTINENCE.
ASSIST FAMILY IN SETTING UP ROUTINE PATIENT-CENTERED AND STRESS THE IMPORTANCE OF ADHERING.
RELAXATION TECHNIQUES
PSYCH ASSESSMENT: ASSESS FOR S/S OF EPS
DETECT AND ALLEVIATE SOMATIZED COMPLAINTS
GOAL ORIENTED TASKS
LIMIT SETTING MOTIVATION TECHNIQUES, IMAGERY TECHNIQUES OTHER:
INST. DISEASE PROCESS AND COMMON COMPLICATIONS INST. LOW SODIUM DIET - STRESSING IMPORTANCE OF
ADHERENCE MONITOR PATIENT'S BLOOD PRESSURE CLOSELY AND NOTIFY M.D OF ANY SIGNIFICANT CHANGES.
INSTRUCT PT. TO AVOID OVER-THE-COUNTER COLD AND SINUS MEDS AS THEY CONTAIN VASOCONSTRICTOR
INST. OF HYPERTENSIVE CRISIS
MONITOR FOR S/S OF ORTHOSTATIC HYPOTENSION.
INSTRUCT PATIENT IN CONSEQUENT PHYSICAL LIMITATIONS, PLANNING AN ADEQUATE LEVEL OF DAILY
ACTIVITIES TEACH PT R/E ARTHRITIS S/S OF EXACERBATION. TEACH THE IMPORTANCE OF GOOD POSTURE,
PREVENT TRAUMA TO JOINTS
INST. PT IN THE USE OF ASSISTIVE DEVICE AS PRESCRIBED.
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IMPROVE THE PT'S ABILITY TO PREVENT OR COPE WITH BREATHING DIFFICULTIES.
INST. INFECTION CONTROL & PULMONARY HYGIENE
INST. COMPLICATIONS IN CARDIOPULMONARY STATUS
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INST. DISEASE PROCESS & COMMON COMPLICATIONS INST. PRESCRIBED DIET & SHOPPING ADVICE. INST. S/S
HYPO/HYPERGLYCEMIA & EMERGENCY PROCEDURES INST. GOOD SKIN CARE & GOOD FOOT CARE, DAILY CARE OF
Diabetes TEETH. INST. DIABETIC CHART. INST. S&A TESTING & READING RESULTS INSTRUCT TO CARRY I.D. THAT INCLUDES
INFORMATION REGARDING DIABETIC STATUS, NAMES & DOSAGE OF MEDS & ACTION TO TAKE IF INSULIN
Foley
INST. S/S INFECTION
FOLEY INSERTION _______FR. FOLEY WITH___________cc BALLON
Mellitus REACTION OCCURS INST. IMPORTANCE OF GOOD PERSONAL HEALTH HABITS, INCLUDING EXERCISE, ADEQUATE
Care
CHANGE Q MONTH & PRN x3 FOR CLOGGED, LEAKING, OR ACCIDENTAL REMOVAL
REST, SLEEP, REGULAR MED CHECK-UPS (INCLUDING PODIATRIC, OPTHAMOLOGIST & DENTIST).
INST. DRESSING CHANGES ________________________. MONITOR FOR S/S COMPLICATIONS & NOTIFY M.D.
INST. FOR S/S: EASY FATIGABILITY, DYSPNEA, PALPITATIONS, ANGINA TACHYCARDIA,
Wound Care MONITOR STATUS OF WOUND OR DECUBITUS (place) ______________
Anemia PALLOR, DIZZINESS, JAUNDICE AND FEVER. INST. FOR G.I. DISTURBANCES. ASSESS FOR CENTRAL
NERVOUS SYSTEM SYMPTOMATOLOGY
OBTAIN APPROPRIATE LAB TESTS AND REPORT FINDINGS TO M.D.
Decubitus INST. INFECTION CONTROL MEASURES
ADMINISTER
PRESCRIBED
INJECTABLE
_________________ USING ______ TECHNIQUE
INST. GOOD NUTRITION TO FACILITATE HEALING
REPORT ANY ELEVATIONS IN TEMPERATURE TO THE M.D.
ASSESS PSYCHOLOGICAL STATUS PROVIDE SUPPORTIVE THERAPY, PROVIDE REMOTIVATION ASSESS
MEASURE AND RECORD WOUND or DECUBITUS SIZE AT SOC AND AT LEAST WEEKLY THEREAFTER
Depression INTERPERSONAL BEHAVIOR. ASSIST PATIENT TO DEFINE PROBLEMS & SOCIAL RELATIONSHIPS. GIVE POSITIVE
OPEN WOUND CARE/DRESSING: CLEANSE WOUND WITH ___________, TO RINSE WITH __________ AND APPLY______________ AND PRN
REINFORCEMENT ENCOURAGE PATIENT TO PERFORM PERSONAL HYGIENE & GROOMING ACTIVITIES
DECUBITUS CARE/DRESSING: CLEANSE WOUND WITH ___________, TO RINSE WITH __________ AND APPLY______________ AND PRN
ASSIST PATIENT TO EXPRESS REALISTIC IDEAS & PLANS. ASSIST PATIENT TO VERBALIZE FEELINGS.
OBSERVE AND RECORD TYPE AND AMOUNT OF DRAINAGE, COLOR, INFECTION: SWELLING, REDNESS, PAIN
PROVIDE SUPPORTIVE AND RELAXATION THERAPY PROVIDE FAMILY THERAPY. ASSESS INTERPERSONAL
Asthma / Respiratory TEACH THE PATIENT HOW TO USE A METERED-DOSE INHALER MAINTAIN EFFECTIVE AIRWAY CLEARANCE Anxiety BEHAVIOR ASSIST PATIENT TO DEFINE PROBLEMS & SOCIAL RELATIONSHIPS. GIVE POSITIVE REINFORCEMENT.
ASSIST PATIENT TO VERBALIZE FEELINGS.
PROMOTE AN EFFICIENT BREATHING PATTER
INST. DISEASE PROCESS & MAINTENANCE
8.
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MANAGEMENT AND EVALUATION OF A PATIENT CARE PLAN TEACHING AND TRAINING: DISEASE PROCESS
General SKIN CARE, WOUND CARE/DRESSING CHANGE, DECUBITUS CARE MEDICATION REGIMEN
DIET/NUTRITION/HYDRATION COMPLICATIONS OF ENT. FEEDING AS INDICATED
PAIN CONTROL MEASURES, SYMPTOM CONTROL MEASURES SINGS/SYMPTOMS OF INFECTION,
SAFETY/PREVENTION OF INJURY EMERGENCY PLANS OXYGEN ADMINISTRATION
Psychiatric
Hypertension
Osteoarthritis
AIDE - ORDERS - FREQUENCY/DURATION:
30
5.
81
TUB/SHOWER BATH
PERSONAL CARE
HAIR COMB
SHAMPOO PRN
ASSIST TO DRESS ASSIST WITH AMBULATION PREPARE SERVE MEALS
GROCERY SHOP
ERRANDS NOTIFY LAST BM IF NONE FOR 3 DAYS
FEET/NAILS CARE PERI CARE
MOUTH/DENTURE CARE
SKIN CHECK ORAL HYGIENE TPR
WASH CLOTHES
LIGHT HOUSEKEEPING ASSIST WITH PERSONAL CARE AND ADL'S
REPORT SIGNIFICANT FINDING TO SN
STRAIGHTEN ROOM & CHANGE LINEN
PT - ORDERS - FREQUENCY/DURATION:
EVALUATE BALANCE AND COORDINATION
EVALUATE ENDURANCE, MOBILITY
NEUROMUSCULAR RE-EDUCATION,
PERFORM PRESCRIBED THERAPEUTIC EXERCISES
NOTIFY SIGNIFICANT FINDING TO MD/AGENCY
BED MOBILITY TRAINING
GAIT TRAINING WITH ASSISTIVE DEVICE
TEACH HOME MAINTENANCE PROGRAM AND STRENGTHENING EXERCISE
EXERCISE BOTH PASSIVE AND ACTIVE EXERCISE REGIMEN TRANSFER TRAINING
INSTRUCT IN SAFETY MEASURES, FALL PRECAUTIONS
OT - ORDERS - FREQUENCY/DURATION:
EVALUATE PATIENT AND HOME FOR SAFETY
ADL TRAINING PROGRAM
INCREASE RIGHT AND LEFT UPPER EXTREMITIES STRENGTH
INCREASE STRENGTH AND COORDINATION
MUSCLE RE-EDUCATION, BODY IMAGE TRAINING
THERAPEUTIC EXERCISE TO (R) AND (L) HAND
PROPRIOCEPTION AND SENSATION.
ST - ORDERS - FREQUENCY/DURATION:
ST FOR EVALUATION
TO PROVIDE ORAL MOTOR EXERCISES INVOLVING LINGUAL AND LABIAL EXERCISES
SPEECH ARTICULATION DISORDER TREATMENT
IMPROVE SPEECH
FACIAL SYMMETRY AND MUSCULATION
IMPROVE DYSPHAGIA
VOICE DISORDER TREATMENT
AURAL REHABILITATION
NON-ORAL COMMUNICATION
LANGUAGE DISORDER TREATMENT
MSW - ORDERS - FREQUENCY/DURATION:
MSW FOR ASSESSMENT OF SOCIAL AND EMOTIONAL FACTORS
COMMUNITY RESOURCE PLANNING
COUNSELING REGARDING MANAGEMENT/ADJUSTMENT TO ILLNESS
LONG RANGE PLANNING AND DECISION MAKING
Page 7 of 8
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ADULT SOC ASSESSMENT
Med. Record #:
Patient Name:
GOALS /REHABILITATION POTENTIAL (Optional) CMS 485 (P OC)
22
Included as reference only, your Professional Staff must review/update/personalize/approve the goals.
SN - GOALS
MR/MS _________________ WILL EXHIBIT VITAL SIGNS WITHIN ACCEPTABLE RANGE AND STABILIZED DISEASE PROCESS.
SAFELY ADMINISTERS INJECTION. COMPREHEND RATIONALE FOR AND IS ABLE TO ROTATE INJECTION SITES.
General VERBALIZES KNOWLEDGE OF DISEASE MANAGEMENT, MEDICATIONS, SIDE EFFECTS, PRECAUTIONS, DIET, FLUIDS, Insulin COMPREHEND SAFETY FACTORS IN SYRINGE/NEEDLE DISPOSAL.
TREATMENT PROGRAM, S/S NECESSITATING MEDICAL ATTENTION, EMERGENCY CARE. Glucometer PATIENT/CG ABLE TO MONITOR BLOOD SUGAR CORRECTLY WITHOUT ASSISTANCE.
ANEMIA CONTROLLED THROUGH MED. REGIMEN. IMPROVED HEMATOLOGIC STATUS.
HEALED WOUND WITHOUT INFECTION OR COMPLICATIONS. DEMONSTRATE PROPER WOUND CARE.
Wound Care
Decubitus
HEALED DECUBITUS WITHOUT INFECTION OR COMPLICATIONS. DEMONSTRATE PROPER DECUBITUS CARE.
Alzheimer's
PT/S.O. SHOULD UNDERSTAND THE NATURE, SYMPTOMS, STAGE, AND PROGRESSION OF ALZHEIMER'S DISEASE.
KNOW HOW TO RECOGNIZE PT'S OWN STRESS AND WAYS TO PREVENT OR REDUCE IT. PROMOTE SOCIAL
INTERACTION AS TOLERATED BY THE PATIENT.
Asthma
DEMONSTRATE STRATEGIES TO BE USED DURING A COUGHING EPISODE. HELP THE PATIENT IDENTIFY FACTORS
THAT MAY CAUSE ASTHMA ATTACKS OR CONTRIBUTE TO THEM.
Respiratory
UNDERSTAND S/S OF BRONCHITIS OR OTHER RESPIRATORY INFECTION, AND DISEASE EXACERBATION.
UNDERSTAND THE DANGERS OF SMOKING, AIR AND CHEMICAL POLLUTANTS, AND RESPIRATORY INFECTION.
UNDERSTAND AND PRACTICE COUGHING AND DEEP-BREATHING EXERCISES.
DAILY COMPLIANCE W/CATHETER CARE. DECREASE RISK OF URINARY INFECTION.
Catheter
CHF
KNOW ABOUT SIGNS, SYMPTOMS, AND PRECIPITATING CAUSES OF CHF. KNOW HOW TO TAKE THE PULSE AND KNOW
TO CONSULT THE DOCTOR BEFORE CONTINUING MEDICATION IF THE PULSE RHYTHM CHANGES. KNOW TO
AVOID SMOKING AND SMOKY ENVIRONMENTS AND PERSONS WITH INFECTIONS, ESPECIALLY RESPIRATORY INFECTIONS.
Hypertension
UNDERSTAND THAT HYPERTENSION IS A CHRONIC DISEASE REQUIRING LIFE LONG TREATMENT. EXHIBIT BLOOD
PRESSURE READINGS CONSISTENTLY WITHIN NORMAL OR SPECIFIED RANGE. DEMONSTRATE ADHERENCE TO A
LOW-SALT, LOW-FAT DIET.
Angina
Osteoarthritis
HELP THE PATIENT ACHIEVE PAIN RELIEVE AND REDUCE ANGINA EPISODES. UNDERSTAND THE CAUSE OF
ANGINA PECTORIS AND POSSIBLE PRECIPITATING FACTORS FOR AN ATTACK. IDENTIFY PERSONAL STRESSORS
THAT MAY CONTRIBUTE TO THE PROBLEM AND BEGIN ELIMINATING OR MINIMIZING THEM. KNOW WAYS TO
REDUCE THE FREQUENCY OF ANGINA EPISODES.
INCREASED PAIN RELIEF. INCREASED STRENGTH AND ENDURANCE. COMPREHEND AND
DEMONSTRATE HOME EXERCISE.
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AIDE - GOALS
RETURN TO SELF-MANAGEMENT OF HEALED FRACTURED.
Fracture
m
Anemia
DISCHARGE PT WHEN BLOOD SUGARS ARE WITHIN THE NORMAL FOR PATIENT RANGE.
Diabetes KNOW THE ACCEPTABLE RANGE FOR BLOOD SUGAR LEVEL. COMPLY WITH DIET RESTRICTIONS..
Mellitus
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Psychiatric
ABLE TO NOTIFY M.D. OF ALTERED/OUT OF RANGE RESULTS.
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STABILIZATION OF PSYCHOLOGICAL STATUS WITHIN DISEASE LIMITS. TO REDUCE THE PATIENT'S ANXIETY LEVEL.
DEPRESION/ANXIETY CONTROLED TROUGH MED. REGIMEN/INTERVENTIONS.
GOOD RETURN TO PREVIOUS LEVEL OF ADLS INDEPENDENTLY.
RETURN TO INDEPENDENT AMBULATION. BE SAFE IN SELF CARE.
FAIR-TO BE ABLE TO CARRY OUT MINIMAL ADLS WITH AVAILABLE HOME SUPPORT.
PATIENT WILL BE ABLE TO FUNCTION WITH ASSISTANCE OF CAREGIVER
WITHIN HE/SHE CURRENT LIMITATIONS AT HOME.
PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HIS/HER CURRENT LIMITATIONS AT HOME.
WILL NOT BE ABLE TO CARRY OUT ADLS WITHOUT MAXIMUM SUPPORT.
SA
PT - GOALS
PATIENT WILL EXPERIENCE A DECREASE IN PAIN
GAIT PATTERN, ENDURANCE, STRENGTH AND BALANCE WILL IMPROVE AND PATIENT WILL DEMONSTRATE
CORRECT BODY MECHANICS W/IN 4-6 WKS. PT/CG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISE
PROGRAM WITHIN 4-6 WKS.
PT/CG WILL COMPREHEND AND DEMONSTRATE HOME EXERCISE
PROGRAM WITHIN _____ WEEKS.
8.
59
40
GAIT PATTERN, ENDURANCE, STRENGTH AND BALANCE WILL IMPROVE AND PT WILL DEMONSTRATE
CORRECT BODY MECHANICS WITHIN _____ WEEKS.
OT - GOALS
81
OT: PATIENT WILL EXHIBIT IMPROVEMENT IN COPING IN ADL'S/IADL'S/ MUSCLE USE/MOTOR
COORDINATION/NEURO RESPONSE/USE OF ORTHOTIC/ SPLINTING AND/OR EQUIPMENT.
30
5.
ST - GOALS
PATIENT WILL DEMONSTRATE FUNCTIONAL COMMUNICATIONS, EXHIBIT MAXIMUM VERBAL AND SENTENCE
FORMULATION AND COMPREHENSION WITHIN DISEASE LIMITS WITHIN _____ WEEKS.
PATIENT WILL DEMONSTRATE APPROPRIATE USE OF FUNCTIONAL VERBAL/NON-VERBAL
COMMUNICATIONS SYSTEMS WITHIN _____ WEEKS.
PATIENT WILL DEMONSTRATE IMPROVED READING/WRITING, USE OF GESTURES/NUMBERS WITHIN _____ WEEKS.
PATIENT WILL DEMONSTRATE IMPROVED SWALLOWING/CHEWING/ORAL/MOTOR CONTROL WITHIN _____ WEEKS.
MSW - GOALS
PATIENT WILL HAVE ADEQUATE SUPPORT TO REMAIN IN HOME WITH ASSISTANCE OF COMMUNITY
RESOURCES FOR FINANCIAL, TRANSPORTATION AND PERSONAL CARE ASSISTANCE WITHIN _____ WEEKS.
Yes
No
DISCHARGE PLANNING DISCUSSED WITH PATIENT:
WILL DISCHARGE THE PATIENT WITHIN 60 DAYS WHEN PATIENT AND/OR
CAREGIVER IS/ARE ABLE TO DEMONSTRATE KNOWLEDGE OF DISEASE MANAGEMENT, S/S COMPLICATIONS.
PATIENT IS ABLE TO FUNCTION INDEPENDENTLY WITHIN HIS/HER CURRENT LIMITATION AT HOME.
PSYCHOSOCIAL EVALUATION WILL BE PERFORMED. PT/CG WILL BE COUNSELED REGARDING MANAGEMENT
& ADJUSTMENT TO ILLNESS /LONG TERM PLANNING AND DECISION MAKING. APPROPRIATE COMMUNITY
RESOURCE REFERRALS WILL BE MADE.
REHAB POTENTIAL:
Poor
Fair
Good
Excellent
ABLE TO REMAIN IN HOME/RESIDENCE/ALF WITH ASSISTANCE OF PRIMARY CAEGIVER/SUPPORT AT HOME
ABLE TO UNDERSTAND MEDICATION REGIMEN, AND CARE RELATED TO HIS/HER DISEASE.
WILL BE DISCHARGE WHEN MAXIMUM FUNCTIONAL POTENTIAL REACHED.
COMMENTS
QA Date Reviewed:
/
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