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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 #:__________________

Ahca Medserv-3008 Form - Medical Certification For Nursing Facility/home- And Community-Based Services Form Page 2

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