Transcription of Blaylock Discharge Planning Risk Assessment Screen
1 Blaylock Discharge Planning Risk Assessment Screen Blaylock Discharge PlanningRisk Assessment Screen 09373 (2010-12)Age55 years or less0 FunctionalStatusIndependent in activities of daily living andinstrumental activities of daily living056 - 64 years1 Dependent in65 - 79 years2 Eating / Feeding180+ years3 Bathing / Grooming1 LivingSituation/SocialSupportLives only with spouse0 Toileting1 Lives with family1 Transferring1 Lives alone with family support2 Incontinent of bowel function1 Lives alone with friend s support3 Incontinent of bladder function1 Lives alone with no support4 Meal Preparation1 Nursing home / residential care5 Responsible for own medication administration1
2 Number ofPreviousAdmissions /EmergencyRoom VisitsNone in the last 3 months0 Handling own finances1 One in the last 3 months1 Grocery Shopping1 Two in the last 3 months2 Transportation1 More than two in the last 3 months3 BehaviourPatternAppropriate0 Number ofActiveMedicalProblemsUp to three medical problems0 Wandering1 Three to five medical problems1 Agitated1 More than five medical problems2 Confused1 Number ofDrugsFewer than three drugs0 Other1 Three to five drugs1 MobilityAmbulatory0 More than five drugs2 Ambulatory with mechanical assistance1 CognitionOriented0 Ambulatory with human assistance2 Disoriented to some spheres (person,place, self, time) some of the time 1 Non ambulatory3 Disoriented to some spheres (person,place, self, time) all of the time 2 SensoryDeficitsNone0 Disoriented to all spheres (person,place, self, time) and some of the time 3 Visual or hearing deficits1 Disoriented to all spheres (person,place, self, time)
3 All of the time4 Visual and hearing deficits2 Comatose5 Scoring Index 0 - 10At risk for home care services11 - 19At risk for Discharge planning20+At risk for placement other than homeCircle all that apply and total. Refer to scoring index for recommendations regarding Discharge Planning . Total ScoreSignature Date (yyyy-Mon-dd)If score is 10 orgreater, refer thepatient fordischargecoordinationSuggested Next Steps
