Nursing Assessment for Home Care - New York State ...

1 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.

2 Address: Hospitalized: From: To: Diagnoses: Hospital Contact: Phone: Patient Status:Is patient alert? Always Can patient direct a home care worker? Yes No Sometimes If no, who is responsible for directing home care workers?

3 Never Name/Relationship: Patient Height: Patient Weight: Recent significant weight loss? Yes No If Yes, amount lost: Impairments:Muscular/Motor:Sensory:NoneP artialTotalNonePartialTotal1. Speech2. Sight3. Hearing 1. Hand/Arm2. Upper Extremities3. Lower Extremities Cardiovascular / Respiratory: NonePartialTotal Describe impact on functional Respiratory2. Cardiac3. Circulatory _____1. Does patient have history of tuberculosis? Yes No Pulmonary Extra pulmonary2.

4 Did patient complete therapy? Yes No 3. Does patient currently have tuberculosis? Yes No Pulmonary Extra pulmonary4. Is patient currently on tuberculosis prophylaxis? Yes No Hx of TB prophylaxis Yes No5. Last documented PPD: Date and result _____ Anergy results if available:_____6. If on tuberculosis treatment, are there 3 negative AFB? Yes No Negative chest x-ray Yes NoNew York State Department of HealthUninsured care ProgramsNursing Assessment - Page 2 of 3 Patient Name:_____ ADAP ID#: 555-_____Agency: _____ Provider Number: _____Mental StatusNeverPartialTotalNeverPartialTotal 1. Oriented place and time2. Anxiety3.

5 Agitated4. Short term memory loss5. Wanders6, Depression7. Impaired judgment 8. Danger to: Others (Aggressive) Self 9. Articulates needs10. Sleep disorder11. Abusive to: Others Self12. Other Cognitive / Mental Status Information: Patient Ability to Take/Administer Medication:Never Sometimes* Always *Complete # Totally independent2. Needs reminding3. Non-compliant4. Needs help preparing5. Needs administration 6. Patient/ care giver can be taught to administer Yes No7. Please explain:If patient is not independent, what arrangements have been made to administer medications?IV Infusion and Injections: # of Times Per WeekPatient requires home infusion via: _____ Central Line Peripheral Line Injections _____Blood work (in the home) _____ Elimination:BowelBladderContinentOccasio nally IncontinentIncontinent Medical Treatment: (Check T all that apply) Please list all medications on AI485:1.

6 Decubitus care2. Dressings - Simple 3. Dressings - Sterile4. Enema5. Catheter care 6. Monitor vital signs 7. Tube feeding 8. Tube irrigation 9. Suctioning10. Oxygen administration 11. Blood tests12. Ambulation exercise13. Rehabilitative therapy14. Physical therapy New York State Department of HealthUninsured care ProgramsNursing Assessment - Page 3 of 3 Patient Name:_____ ADAP ID#: 555-_____Agency: _____ Provider Number_____Identification of Service Needs:Without HelpWithCaneWith WalkerWithWheelchairWithPersonalAssistan ceUnableAmbulate insideAmbulate outsideGet up from seated positionGet up from bedTransfer to: Commode Wheelchair Indicate Patient s Personal Service Needs.

7 IndependentPartialAssistTotalAssistIndep endentPartialAssistTotalAssistGroomingDr essingWashingBathingFeedingMeal PrepReheat Meals Toileting/ Bathroom Urinal or bedpan Commode CatheterLaundryShoppingHousecleaning Is the patient homebound? Yes No**If patient is not homebound, you must submit justification of home care :This Assessment is based on personal observation of the patient. Yes NoThis Assessment is based on information relayed to me by: _____Prepared by: (print name)_____ Phone #:_____Agency Affiliation:_____ FAX#: _____Signature:_____ Date: _____Is any other agency/vendor providing services in the home to the patient?

8 Yes NoIf Yes, Agency Name:_____Services:_____Have all home care insurance benefits been exhausted? Yes NoIs this patient eligible for Medicaid? Yes No Have they applied to Medicaid? Yes NoIf No, State reasons:_____FOR NEW HOME care APPLICANT ONLY:How was the applicant referred to your agency? Doctor Social Worker Discharge Planner Location:_____ Other Please explain:_____(Rev. 12/2005)