msh long term home care follow-up oasis assessment page 1
Post on 01-Oct-2021
0 Views
Preview:
TRANSCRIPT
NURSING ASSESSMENT/REASSESSMENT
Client Last Name
Client First Name Date of Assessment
Client Date of Birth
Age FRA +1 if 65+ Male Female
Primary Diagnosis
Secondary Diagnosis
Tertiary Diagnosis FRA +1
Other Diagnoses
Diagnoses Known By Patient Family Primary Caregiver
Are Diagnoses Consistent with Last Assessment? Yes No (changes)
Recent Hospitalization(s)
Significant Medical/Surgical History
A
LLER
GIE
S
Assessed, No Allergies Reported (environmental, drug, food, or otherwise)
Allergies Reported
Penicillin Sulfa Medications Animal Dander Latex Dust Pollen
Bee Stings Milk/Dairy Products Nuts Eggs Other
Comments
Sees specialist for positive findings (name)
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
PH
YSI
CA
L
Eyes Assessed, No Problems Reported
Vision Issues FRA +1 Left Right
Glaucoma Cataracts Macular Degeneration Legally Blind
Glasses/Corrective Lenses Distance Reading
Ears Assessed, No Problems Reported
Auditory Issues
Hard of Hearing Deaf Discharge Hearing Aid
Nose & Sinus Assessed, No Problems Reported
Nasal Issues Left Right
Epistaxis Drainage Congestion
Loss of Smell Sinus Problems
Neck & Throat Assessed, No Problems Reported Otolaryngology Issues Hoarseness Sore Throat Lesions
Oral Assessed, No Problems Reported
Oral Issues Upper Lower
Dentures Partial Bridge
Difficulty Chewing/Swallowing Episodes of Choking Other
Mobility No Problems Reported
Mobility Issued Reported
Uses Equipment (see below) Requires Supervision Fall Within 3 Months FRA +1
Comments
Sees specialist for positive findings (name)
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
Nursing Reassessment (4/16) Page 1 of 8 FRA Page Tally: _____
NY Non-Waiver Patient Onboarding Kit 9/17
Client Initials
Nursing Reassessment (4/16) Page 2 of 8 FRA Page Tally: _____
EQU
IPM
ENT
Assessed, No Equipment in Home
Equipment in Home
Walker Cane Wheelchair Hospital Bed Lift
Commode Shower Bench/Chair Raised Toilet Seat Grab Bars
Nebulizer Medication Box PERS Other
Was equipment management reviewed? Yes No
Comments
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
V
ITA
L SI
GN
S
Blood Pressure / Lying Sitting Standing Pulse Regular Irregular Respirations /min Regular Irregular Labored Temperature Orally Rectally Axillary Comments
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
N
UTR
ITIO
NA
L &
DIE
TA
RY
INT
AK
E
Appetite
Diet Fluids
Quantity Restrictions per day Non-Compliant with Diet/Fluids/Restriction
GT Feeds times daily Dietary Supplements Type Amount per day
Weight lbs As Reported by Client Client Scale Approximate, Unable to Weigh
Recent Change Increase lbs in months Decrease lbs in months
Height As Reported by Client
Nutritional Risk Screen (“NRS”)
Has an illness or condition that necessitates a special diet NRS +1
Eats fewer than 2 meals per day NRS +1
Eats only a few fruits, vegetables, or milk products NRS +1
Has 3 or more drinks of alcohol daily NRS +1
Has teeth or mouth problems making eating difficult NRS +1
Does not have enough money to purchase food NRS +1
Eats alone most of the time NRS +1
Takes 3 or more prescribed or OTC drugs per day NRS +1
Unintentionally lost or gained 10 lbs in the last 6 months NRS +1
Not always able to shop, cook, and/or feed self NRS +1
NSR TOTAL:
NRS total equals 10 so client is considered high risk – REFER FOR MD FOLLOW UP –
Comments
Sees specialist for positive findings (name)
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
NY Non-Waiver Patient Onboarding Kit 9/17
Client Initials
Nursing Reassessment (4/16) Page 3 of 8 FRA Page Tally: _____
C
AR
DIO
PU
LMO
NA
RY
Assessed, No Problems Reported
Cardiovascular Issues
History HTN CHF MI CAD Bypass Stent High Cholesterol Angina
Current Dyspnea on Exertion Fatigues Easily Syncope
Lower Extremity Edema Pitting Non-Pitting
Chest Pain Angina associated with Activity Sweats SOB
Frequency/Duration Relief
Pacemaker MD Following/Checking
Comments
Sees specialist (e.g., Cardiologist) for positive findings (name)
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
M
USC
ULO
SKEL
ETA
L &
NE
UR
OLO
GIC
AL
Musculoskeletal
Assessed, No Problems Reported
Musculoskeletal Issues FRA +1
History Osteoarthritis Rheumatoid Arthritis Joint Replacement
Current Tremor Cramps Weakness Stiffness Limited ROM
Decreased Coordination Decreased Muscle Strength Unsteady Gait
Swelling Deformity Contractures
Paralysis/Paresis side Other
Neurological
Assessed, No Problems Reported
Neurological Issues FRA +1
History Seizures Syncope CVA TIAs Parkinson’s
Current Numbness Unequal Grasp Headaches Poor Balance Dizziness
Seizures (type/last occurrence) Other
Comments
Sees specialist (e.g., Neurologist) for positive findings (name)
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
R
ESP
IRA
TO
RY
Assessed, No Problems Reported
Breathing Issues
History Asthma Bronchitis Cancer Pneumonia COPD TB
Sleep Apnea CPAP BiPAP Vendor
Current Sounds Diminished Rales Rhonchi Crackles Wheezing
Pursed Lips Breathing Dyspnea on Exertion Nasal Flaring SOB
Inhaler Nebulizer Cough Productive Dry
Vent Settings Type
Frequency Checked By
Trach Size Brand
O2 Use Type Flow liters/min Backup Tank
Frequency Continuous PRN Night Other
Via Nasal Prongs Mask Trach Vent
Comments
Sees specialist for positive findings (name)
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
NY Non-Waiver Patient Onboarding Kit 9/17
Client Initials
Nursing Reassessment (4/16) Page 4 of 8 FRA Page Tally: _____
R
EPR
OD
UC
TIV
E
Assessed, No Problems Reported
Issues with Reproductive Organs
History Cancer (type) Hysterectomy Mastectomy BPH TURP
Current Discharge/Drainage Inflammation Cysts Lesion/Mass
Preventive OB/GYN Care Pregnant
Comments
Sees specialist for positive findings (name)
The above is different from the previous assessment conducted (differences) A
BD
OM
EN/G
AST
RO
INTE
STIN
AL
Assessed, No Problems Reported
Abdominal/Gastrointestinal Issues
History Cancer Colitis Ulcers Diverticulitis Polyps GERD
Gallbladder Disease/Surgery GI Bleed
Current Distention Hernia Ascites (girth) cm
Tenderness Palpable Mass Hypoactive Sounds Hyperactive Sounds
Nausea Vomiting Frequency Amount
Indigestion Cramps Flatulence Heartburn Bleeding
Hemorrhoids Internal External
Ostomy (type) Excoriated Stoma Appliance
Comments
Sees specialist for positive findings (name)
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
EL
IMIN
ATI
ON
Bowel Last BM (date) Usual Bowel Frequency per day
Assessed, No Problems Reported
Bowel Issues
Diarrhea Acute Occasional per day Chronic
Constipation Acute Occasional per day Chronic
Incontinent FRA +1 Always Occasional
Impacted Laxative and/or Enema Use (regimen)
Recent Change Abnormal Stool
Genitourinary
Assessed, No Problems Reported
Genitourinary Issues
History Recurrent UTIs Renal Failure Cancer Nephrostomy
Current No Problems Reported
Urinary Issues
Frequency Burning Urgency Hematuria Nocturia
Incontinent FRA +1 Always Occasional Day Night
Diapers Pads
Dialysis Hemodialysis Peritoneal Su M Tu W Th F Sa
Catheter Indwelling Suprapubic External Straight
Size Frequency Last
Responsible Party
Comments
Sees specialist for positive findings (name)
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
NY Non-Waiver Patient Onboarding Kit 9/17
Client Initials
Nursing Reassessment (4/16) Page 5 of 8 FRA Page Tally: _____
END
OC
RIN
E &
HEM
ATO
PO
IETI
C
Assessed, No Problems Reported
Endocrine/Hematopoietic
Thyroid Issue Heat/Cold Intolerance Excessive Bleeding
Anemia Pernicious Iron Deficiency 2 Bleed Other
Diabetes Type 2 (NIDDM)
Type 1 (IDDM) Present Blood Glucose Result mg/dl
Random Blood Sugar (time tested)
Usual Range mg/dl
Frequency Checking/Managing
Person Responsible for Checking
Uses Insulin Self-Administers Administered by
Needs Instruction on Glucose Monitoring Non-Compliant with Glucose Monitoring
Comments
Sees specialist for positive findings (name)
Feet checked by Podiatrist
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
EM
OTI
ON
AL/
BEH
AV
IOR
AL
Consciousness Alert Lethargic Nonresponsive
Orientation Person Place Time
Cognition Comprehension Impaired/Decreased (e.g., confused, impulsive, memory deficits) FRA +1
Mood Calm Angry Anxious Agitated
Depressed Withdrawn Fearful
Behavior Appropriate Non-compliant Wanders Indifferent
Hostile Suspicious Verbally Abusive Physically Abusive
Perception Appropriate Hallucinations
Sleep/Rest No Problems Insomnia Disturbance(s) Uses Sleep Aid
Comments
Behavioral health needs are managed? Yes No Referral for Psych Indicated
Sees specialist for positive findings (name)
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
M
EDIC
ATI
ON
MA
NA
GEM
ENT
Assessed, No Medications Reported
Medication(s) Taken (Complete Medication Profile and assess the following)
Four or more prescriptions taken (any type)? Yes No
Does client report compliance with medications? Always Sometimes Never
Does the supply at hand reflect compliance? Yes No
Would the client benefit from a medication box? Yes No
Do any medications require pre-pour/administration? Yes No
If yes, name and relationship of responsible person
Does this person need instruction? Yes No
Are there any diagnoses without a corresponding medication? Yes No
If yes, explanation
Are there any medications without a corresponding diagnosis? Yes No
If yes, explanation
Comments
Sees specialist for positive findings (name)
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
NY Non-Waiver Patient Onboarding Kit 9/17
Client Initials
Nursing Reassessment (4/16) Page 6 of 8 FRA Page Tally: _____
PA
IN
Assessed, No Pain Reported
Pain Location Onset/Duration
Level/Intensity
Ache Prick Throbbing Burning Sharp
Shooting Dull Pulling Other
Is pain impacting level of function? Yes FRA +1 No
What is the current pain regimen?
Is current pain regimen effective? Yes No (reason)
Comments
Sees specialist for positive findings (name)
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
SK
IN
Assessed, No Problems Reported
Dermatologic Issues
History Decubitis Venous Stasis Ulcer Cellulitis Diabetic Ulcer
PVD Slow/Poorly Healing Wound(s)
Current Bruises Scabs Burns Abrasions Lesions
Cellulitis Lacerations Fistula Stoma Keloids
Scars Rash Flushed Parlor Jaundiced
Cyanotic Incision Ashen Dry/Flaky Scaly
Pruritus Erythema Petechiae Decubiti/Wound
Indicate any identifying marks, scars, amputated limbs, and/or wounds/ulcers/lesions/rashes requiring care on the body below:
Comments
Name of individual managing would care, if applicable
Sees specialist for positive findings (name)
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
NY Non-Waiver Patient Onboarding Kit 9/17
Client Initials
Nursing Reassessment (4/16) Page 7 of 8 FRA Page Tally: _____
IMM
UN
IZA
TIO
N
None Refused, Education Provided
Pneumonia (date) Influenza (date) Hepatitis B (date)
Tetanus (date) Other (date)
Comments
Sees specialist for positive findings (name)
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
H
OM
E SA
FET
Y
Supplies, Equipment, Electrical
Extension cord properly used? Yes No N/A
All electrical medical equipment properly grounded? Yes No N/A
Electrical cords and telephone cords safely positioned and in good repair? Yes No N/A
Electrical appliances away from tub/shower? Yes No N/A
Medications stored in safe appropriate place? Yes No N/A
Outdated medications discarded? Yes No N/A
Storage/handling of oxygen and other supplies safe and appropriate? Yes No N/A
Proper storage of hazardous materials? Yes No N/A
Proper storage or handling of food? Yes No N/A
Home Environment FRA +1 If One or More No’s
Skid resistant mats in place? Yes No N/A
Grab bars, tub bench in place? Yes No N/A
Adequate heat/cooling ventilation and light? Yes No N/A
Scatter rugs secured? Yes No N/A
Appropriate footwear? Yes No N/A
Adequate space for care? Yes No N/A
Rooms free from clutter and objects (including pets) that impair mobility? Yes No N/A
Fire/Emergency
Smoke detectors present and working on each level of the home? Yes No N/A
Knowledgeable in accessing emergency assistance? Yes No N/A
Planned escape route from all rooms of the home? Yes No N/A
Smoking safety guidelines followed? Yes No N/A
Has emergency preparedness kit and/or extra medications/supplies? Yes No N/A
Has emergency plan in event of disruption of services? Yes No N/A
Comments
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
FA
LL R
ISK
ASS
ESSM
NT
Fall Risk Assessment Score (FRA total)
FRA total is greater or equal to 5 so client is considered high risk Falls Precaution Sheet Completed
Comments
Sees specialist for positive findings (name)
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
NY Non-Waiver Patient Onboarding Kit 9/17
Client Initials
Nursing Reassessment (4/16) Page 8 of 8 FRA Page Tally: _____
EM
ERG
ENC
Y P
REP
AR
EDN
ESS
Priority Code (Select one. Must be determined by clinician, independent of service hours)
Level 1 High Priority – Requires uninterrupted service(s)/must have care. In case of disaster, every possible effort must be made to provide service(s) to client
Level 2 Moderate Priority – Services may be postponed with telephone contact. A caregiver can provide basic care until the emergency situation improves
Level 3 Low Priority – May be stable and has access to informal supports. Client can safely miss a scheduled visit
Transportation Assistance Level (Select one. Indicates transportation needs during planned regional/statewide evacuation) TAL 1 Non-Ambulatory – Requires transport by stretcher
TAL 2 Wheelchair-Bound – Unable to walk due to physical and/or medical condition
TAL 3 Ambulatory – Able to walk without physical assistance
Flood Zone (if known)
Comments
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
Based upon this assessment (including diagnoses and medication profile), the following precautions should be entered on the Form CMS-485 and aide plan of care (in addition to Standard/Universal):
Bleeding Skin Hypo/Hyperglycemia Seizure Sharps Aspiration Falls Oxygen
Patient has verified that the following Primary Care Provider information is accurate:
Name: Address: Telephone #:
Significant needs/conditions/changes were observed that might be addressed through palliative care
If palliative care is indicated, I have provided related information/facilitated access to consultation
Additional Narrative Notes
Plan of Care discussed with client/caregiver? Yes No (reason)
Signature
Print Name & Title Date
NY Non-Waiver Patient Onboarding Kit 9/17
top related