Nursing Assessment for Home Care Page 1 of 3
Patient Information:
Last Nam e: First Nam e: Middle Initial:
ADAP ID Num ber: 555- Social Security Num ber:
Contact Person (Nam e & Relationship):
Contact Phone (Day-tim e): Please submit release to allow Program contact.
Living Situation:
Dwelling: Apartm ent House Other: Floor: # of Room s: Elevator: Yes No
Lives alone: Yes No Identify all individuals living in the hom e:
List the services, hours and days they are available and able to assist with care giving:
Hospitalization:
Hospital Nam e: Address:
Hospitalized: From : To: Diagnoses:
Hospital Contact: Phone:
Patient Status:
Is patient alert? Always Can patient direct a hom e care worker? Yes No
Som etim es If no, who is responsible for directing home care workers?
Never Nam e/Relationship:
Patient Height: Patient W eight:
Recent significant weight loss? Yes No If Yes, am ount lost:
Impairments:
Sensory: Muscular/Motor:
None Partial Total None Partial Total
1. Speech 1. Hand/Arm
2. Sight 2. Upper Extrem ities
3. Hearing 3. Lower Extrem ities
Cardiovascular / Respiratory:
None Partial Total Describe im pact on functional ability.
1. Respiratory ________________________________________________
2. Cardiac ________________________________________________
3. Circulatory
1. Does patient have history of tuberculosis? Yes No Pulm onary Extra pulm onary
2. Did patient com plete therapy? Yes No
3. Does patient currently have tuberculosis? Yes No Pulm onary Extra pulm onary
4. Is patient currently on tuberculosis prophylaxis? Yes No Hx of TB prophylaxis Yes No
5. Last docum ented PPD: Date and result ________________ Anergy results if available:____________________
6. If on tuberculosis treatm ent, are there 3 negative AFB? 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:______________________________________________________ ADAP ID#: 555-_________________
Agency: ___________________________________________________________ Provider Num ber: ______________
Mental Status
Never Partial Total Never Partial Total
1. Oriented place and tim e 8. Danger to: Others (Aggressive)
2. Anxiety Self
3. Agitated 9. Articulates needs
4. Short term m em ory loss 10. Sleep disorder
5. W anders 11. Abusive to: Others
6, Depression Self
7. Im paired judgm ent 12. Other Cognitive / Mental
Status Inform ation:
Patient Ability to Take/Administer Medication:
Never Som etim es* Always *Com plete #7.
1. Totally independent 6. Patient/care giver can be
2. Needs rem inding taught to adm inister Yes No
3. Non-com pliant 7. Please explain:
4. Needs help preparing
5. Needs adm inistration
If patient is not independent, what arrangem ents have been m ade to adm inister m edications?
IV Infusion and Injections: # of Times Per W eek
Patient requires hom e infusion via: ______________
Central Line Peripheral Line
Injections ______________
Blood work (in the hom e) ______________
Elimination:
Bowel Bladder
Continent
Occasionally Incontinent
Incontinent
Medical Treatment: (Check T all that apply) Please list all medications on AI485:
1. Decubitus care 6. Monitor vital signs 11. Blood tests
2. Dressings - Sim ple 7. Tube feeding 12. Am bulation exercise
3. Dressings - Sterile 8. Tube irrigation 13. Rehabilitative therapy
4. Enem a 9. Suctioning 14. Physical therapy
5. Catheter care 10. Oxygen adm inistration
New York State Department of Health
Uninsured Care Programs Nursing Assessment - Page 3 of 3
Patient Name:_____________________________________________________ ADAP ID#: 555-_________________
Agency: __________________________________________________________ Provider Num ber_______________
Identification of Service Needs:
W ithout W ith W ith W ith W ith
Help Cane W alker W heelchair Personal Unable
Assistance
Am bulate inside
Am bulate outside
Get up from seated position
Get up from bed
Transfer to:
Com m ode
W heelchair
Indicate Patient’s Personal Service Needs:
Partial Total Partial Total
Independent Assist Assist Independent Assist Assist
Groom ing Toileting/ Bathroom
Dressing Urinal or bedpan
W ashing Com m ode
Bathing Catheter
Feeding Laundry
Meal Prep Shopping
Reheat Meals Housecleaning
Is the patient homebound? Yes No*
*If patient is not hom ebound, you m ust subm it justification of hom e care separately.
Certification:
This assessm ent is based on personal observation of the patient. Yes No
This assessm ent is based on inform ation relayed to m e by: ______________________________________________
Prepared by: (print nam e)___________________________________________ Phone #:_____________________
Agency Affiliation:_________________________________________________ FAX#: _______________________
Signature:________________________________________________________ Date: ________________________
Is any other agency/vendor providing services in the hom e to the patient? Yes No
If Yes, Agency Nam e:___________________________________Services:__________________________________
Have all hom e care insurance benefits been exhausted? Yes No
Is this patient eligible for Medicaid? Yes No Have they applied to Medicaid? Yes No
If No, state reasons:_____________________________________________________________________________
FOR NEW HOM E CARE APPLICANT ONLY:
How was the applicant referred to your agency?
Doctor Social W orker Discharge Planner Location:___________________________________________
Other Please explain:___________________________________________________________________________
(Rev. 12/2005)
