NURSING/SOCIAL WORK ASSESSMENT
[Page 2 may be completed by a Nurse or Social Worker]
ADLs ARE AT TIME
INDIVIDUAL'S NAME _____________________________________________
DOB ____________________
OF NF ADMISSION
(K) VISION
1. Good
3. Poor
1. No assistance
4. Requires assistance*
AMBULATION
(w/glasses if
2. Fair
4. Blind
2. With assistive device
5. Total help
used)
3. With supervision
6. Bed bound
HEARING
1. Good
3. Poor
1. Tolerates distance (250 feet sustained activity)
ENDURANCE
(w/aid if
2. Fair
4. Deaf
2. Needs intermittent rest
4. No tolerance
used)
3. Rarely tolerates short acitivities
1. Good
4. Gestures or signs
1. No assistance
4. Requires assistance*
SPEECH
TRANSFER
2. Fair
5. Unable to speak
2. With assistive device
5. Bed bound
3. Poor
3. With supervision
COMMUNI-
WHEELCHAIR
1. Transmits messages/receives information
1. No assistance
3. Wheels a few feet
CATION
USE
2. Limited ability
2. Assistance with
4. Unable
3. Nearly or totally unable
difficult maneuvering
N/A
MENTAL
1. Alert
5. Aggressive
9. Safety restraints needed
1. No assistance
A- Bathroom
AND
2. Confused
6. Disruptive
10. Well motivated
2. With assistive devices
B - Bedside commode
BEHAVIOR
TOILETING
3. Disoriented
7. Apathetic
3. With supervision
C- Bedpan
STATUS
4. Comatose
8. Wanders
4. Requires assistance
5. Total assistance
1. Intact
5. Decubitus
1. Continent
SKIN
2. Dry/Fatigue
Site:__________________
2. Occasional incontinence - once/week or less
BLADDER
CONDITION
3. Irritations (rash)
Stage:_________________
3. Frequent incontinence - up to once a day
CONTROL
4. Open Wound
Size:__________________
4. Total incontinence
5. Catheter - indwelling
1. No assistance
1. Continent
2. Supervision
2. Occasional incontinence-once/week or less
BOWEL
DRESSING
3. Requires assistance*
3. Frequent incontinence - up to once a day
CONTROL
4. Has to be dressed
4. Total incontinence
5. Ostomy
1. No assistance
A- Tub
1. No assistance
5. Aspirates
2. Supervision
B - Shower
2. Tray set up only
BATHING
FEEDING
3. Requires assistance*
C- Sponge Bath
3. Requires assistance
4. Is bathed
4. Is fed
TEACHING
1. Diabetic
3. Ostomy
1. Full
3. Pureed
DIET
NEEDS
2. Cardiac
4. Other (specify):
2. Mechanical Soft
4. Other (specify):
*(HANDS ON NEEDED)
Comments:___________________________________________________________________________________________________________________
SIGNATURE AND TITLE________________________________________________________________________DATE_________/_________/_________
(L)
SOCIAL WORK ASSESSMENT
Prior Living Arrangement_______________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Long Range Plan/Agency Referrals_______________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Adjustments to Illness or Disability_______________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Comments ___________________________________________________________________________________________________________________
AHCA MEDSERV-3008 form, May 2009--(Replaces Patient Transfer and Continuity of Care Form 3008 July 2006 - CF Med 3008)
DCF ACCESS Confirmation #:__________________