Transcription of Nursing Assessment for Home Care - New York State ...
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Nursing Assessment for Home Care Page 1 of 3 Patient Information:Last Name: First Name: Middle Initial: ADAP ID Number: 555- Social Security Number: Contact Person (Name & Relationship): Contact Phone (Day-time): Please submit release to allow Program Situation:Dwelling: Apartment House Other: Floor: # of Rooms: Elevator: Yes NoLives alone: Yes No Identify all individuals living in the home: List the services, hours and days they are available and able to assist with care giving: Hospitalization:Hospital Name: Address.
Sen sor y: Muscular/Motor: N one Par tial T ot al N one Par tial T ot al 1. Speech 2. Sight 3. Hearing ... ‚ 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: ...
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