49 North Airmont Rd, Montebello NY 10901 Phone: 845-425-6555; Fax: 845-425-9035

Patient Name: DOB: AGE: TIME: SOC Date:

PT Address: Emergency Contact Name: Phone #:

Pharmacy Name Phone #:  Physician Name: Phone #:

NON SKILLED ASSESSMENT / REASSESSMENT

The following were discussed with the patient and/or caregiver prior to provision of care

  • Rights and responsibilities      
  • Charges for services                              
  • Pt/caregiver development of care plan
  • Complaint procedure                  
  • Goals of visits
  • Services provided      
  • Discharge planning
  • EVV
  • Fire/safety/disaster emergency plan                  
  • Privacy notice
  • Infection control/PPE use
  • Advance directive

Diagnosis:

Prognosis: Good Fair Poor

Allergies:

Advanced Directive Yes No If yes, list:

Mental Status: Oriented  Confused  Forgetful  Other  


IMMUNIZATIONS

Influenza Vaccine:

 

Pneumonia Vaccine:

Covid-19 Vaccine:

Details:

 

VITAL SIGNS

Temp: Pulse: Blood Pressure: Second Reading: Resp: Weight:        Height:  

 
Patient  Family/Friend  aide will assist/remind  NA  
Interventions

Pain Scale: Pain location: Pain Description:

Intervention:

Effectiveness

Functional Limitations:
Ambulation       Bowel/bladder (incontinence)    Hearing     Endurance    Dyspnea     Vision     Others (specify) 
Activities Permitted:   Up as tolerated     transfer bed/chair     cane     wheelchair    walker      Others (specify) 

Any falls within the last 6 months? Yes No   Educated on Fall Precautions

List safety measures/Precautions:
 Fall precaution    Keep pathways clear     Bleeding precautions      Oxygen precautions      Infection/standard precaution                                 Others (specify)  


Family supportive: Yes No Caregiver Name: Relationship:

Medication Management Self Family/Friend Other agency (name: )


DME and supplies

CANE WALKER WHEELCHAIR GRAB BARS BEDSIDE COMMODE TUB/SHOWER BENCH HOSPITAL BED OXYGEN RAISED TOILET SEAT DIABETIC SUPPLIES PERS NEBULIZER INCONTINENCE PRODUCTS Glucometer Hand Held Shower Device ROLLATOR WALKER OTHERS  

HOYER LIFT

HEALTH STATUS ASSESSMENT


REVIEW OF SYSTEMS

 

VITAL SIGNS 
 

  Yes No




Blood Pressure greater than:
Blood Pressure less than:
Heart Rate:
Blood Sugar:
Respiratory rate:
 

 

The following are to be discussed with the patient and/or caregiver during the review of systems, when applicable.

  • Referral (CHAA or collab with MLTC)      
  • Interdisciplinary agency collaboration
  • Medical provider
  • Education provided

 

NEUROLOGICAL:

VISION & HEARING:

MUSCULOSKELETAL:

INTEGUMENTARY:

 

 

  • Type of skin impairment
  • Measurement ( Length, width, depth)      
  • Location
  • Responsible Party
  • Drainage

Additional Information:

 

RESPIRATORY:

CARDIOVASCULAR:

ENDOCRINE:

REPRODUCTIVE/GENITAL:

GENITOURINARY:

GASTROINTESTINAL:

 


ELIMINATION STATUS


Urinary Incontinence or Urinary Catheter Presence : No incontinence Foley Catheter Patient is incontinent
When does Urinary Incontinence occur? Timed-voiding defers incontinence    during the night only    during the day and night

Type of Foley : Internal Suprapubic Ileostomy External M/F catheter Nephrostomy Other
Responsible party : self care    Other    Name:    Phone:


Bowel Incontinence : Yes No
Appliance : Yes No
 

Location of stoma : Comments :
Type : Colostomy Other
Responsible party : self care    Other    Name:    Phone:

 

 

 

NUTRITIONAL SCREEN:

Gtube : Yes No
Responsible party : self care    Other    Name:    Phone:

Check All that Apply:






 
 


NUTRITION RISK/ INTERVENTION:
 Impaired or inadequate food and fluid intake/difficulty chewing or swallowing 
Issues with availability of food and fluid for patient
: comorbidity, multiple medications, dentures

Intervention:    
Refer to MD for eval   MLTC referral     Provide resources/education   Interdisciplinary follow up

DIETChoose one diet that is most appropriate:
Regular Diet   
 

 

ADLS/FUNCTIONAL ASSESSMENT
  1. Grooming: Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or make up, teeth or denture care, fingernail care) Able to groom self needs assistance for grooming
  2. Ability to Dress (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, slacks, socks shoes buttons, and snaps: Able to dress self needs help to put on clothing
  3. Bathing: Ability to wash entire body. Excludes grooming (washing face and hands only) Able to bathe self in shower or tub independently Needs assistance or supervision to bathe
  4. Toileting: Ability to get to and from the toilet or bedside commode. Able to get to and from the toilet independently Needs assistance or supervision to use the toilet
  5. Transferring: Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if member is bedfast Able to independently transfer with or without assistive device Transfers with assistance of a person or totally dependent for transfer
  6. Ambulation/Locomotion: Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces. Able to walk alone with or without assistive device or able to wheel self Requires assistance to walk or wheel a chair Non ambulatory
  7. Feeding or Eating: Ability to feed self meals and snacks. Note: This refers only to the process of eating, chewing, and swallowing, not preparing the food to be eaten. Able to independently feed self requires assistance or supervision
  8. Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals Able to independently prepare or heat meals Needs assistance
  9. Laundry: Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand. Able to independently take care of laundry tasks requires assistance
  10. Housekeeping: Ability to safely and effectively perform light housekeeping and cleaning tasks Able to independently perform housekeeping tasks requires assistance
  11. Shopping: Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery Able to independently perform shopping tasks Needs someone to do all shopping and errands

Goals

Patient will: remain safe in the community comply with his/her diet and medication regimen not be hospitalized during this cert period

Does this Patient need Palliative care: No Yes (if yes refer to MD/case manager)

D/C PLAN: None at this time at request of patient or vendor to other agency when this agency can no longer care for the patient

Services and frequency

Nurse HHA PCA PRIORTY CODE

TALS

Electronic device dependency: Bi-pap IV-pump TPN Feeding pump Oxygen Ventilator

Progress Note

Also submit to the Coordination department

I have been informed that community homecare participates in a CDPAP

I participated and agreed with the plan of care developed together with my nurse

I have participated in the creation of my individual Plan of Care, and received a copy that will remain in my home.

Patient Signature:

Reset Signature

 Authorized Agent Signature:
 

Reset Signature

Reason Patient unable to sign

If patient is unable to sign and this box is checked please enter N/A in the patient signature box    		 Print Name:
Relationship:
Today's Date
RN Signature

Reset Signature

Print RN Name:
 

MEDICATION PROFILE

 

DRUG NAME DOSE AMOUNT FREQ ROUTE COMMENTS PARAMETERS

I have reviewed the medications to identify any potential adverse effects, drug parameters and drug reactions including ineffective drug therapy, significant side effects, significant drug interactions and duplicate drug therapy.

SAFETY ASSESSMENT ENVIRONMENT
  YES NO   YES NO
Clean Toilet seat proper level
Uncluttered Tub/shower
Safe neighborhood Seat in tub/shower
Smoke detectors Handgrips in tub/shower
Uncluttered walking path Air-conditioning
Adequate furnishings Heat
Furniture w/o sharp edges Posted emergency numbers
Storage waist to eye level Unbuckled carpets
Adequate storage space Scatter rugs-non stick backs
Lights easily reached Non-skid treads on steps
Phone easily accessible Stair hand rail
Adequate electricity Non-skid wax on floors
Outlets properly accessed Steps for entrance
Electric cords along walls Uneven walk surfaces marked
Adequate lighting Stove
Outlets not overloaded Refrigerator
Unfrayed electrical cords Wheeled furniture secured
Adequate use of night lights Lifeline
Flushing toilet Fire/disaster evacuation plan
Other: Other:
Other: Other:

Lives: Alone Spouse Family Other

 

 

Private home Apartment Multi level

Walk up Elevator # of Rooms


Safety Assessment Comments:

Also submit to the Coordination department


                                                                                           
 

                                 

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