Sample Assisted Living Health Care Practitioner Physical Assessment​​

Assisted Living

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Health Care Practitioner Physical Assessment Form

 

This form is to be completed by a primary physician, certified nurse practitioner, registered nurse, certified nurse-midwife or physician assistant. Questions noted with an asterisk are “triggers” for awake overnight staff.

 

 

Please note the following before filling out this form: Under Maryland regulations an assisted living program may not provide services to a resident who, at the time of initial admission, as established by the initial assessment, requires: (1) More than intermittent nursing care; (2) Treatment of stage three or stage four skin ulcers; (3) Ventilator services; (4) Skilled monitoring, testing, and aggressive adjustment of medications and treatments where there is the presence of, or risk for, a fluctuating acute condition; (5) Monitoring of a chronic medical condition that is not controllable through readily available medications and treatments; or (6) Treatment for a disease or condition that requires more than contact isolation. An exception to the conditions listed above is provided for residents who are under the care of a licensed general hospice program.

 

 

1.* Current Medical and Psychiatric History. Briefly describe recent changes in health or behavioral status, suicide attempts, hospitalizations, falls, etc., within the past 6 months.

 

 

2.* Briefly describe any past illnesses or chronic conditions (including hospitalizations), past suicide attempts, physical, functional, and psychological condition changes over the years.

 

 

  1. Allergies. List any allergies or sensitivities to food, medications, or environmental factors, and if known, the nature of the problem (e.g., rash, anaphylactic reaction, GI symptom, etc.). Please enter medication allergies here and also in Item 12 for medication allergies.

 

 

  1. Communicable Diseases. Is the resident free from communicable TB and any other active reportable airborne communicable disease(s)?

(Check one)   Yes      No       If “No,” then indicate the communicable disease:      

 

Which tests were done to verify the resident is free from active TB?

PPD                                                                                           Date:         Result:      mm

Chest X-Ray (if PPD positive or unable to administer a PPD)        Date:         Result:      

 

 

 

Resident Name         

Date of Birth             

Date Completed        

 

  1. History. Does the resident have a history or current problem related to abuse of prescription, non-prescription, over-the-counter (OTC), illegal drugs, alcohol, inhalants, etc.?

(a)    Substance:  OTC, non-prescription medication abuse or misuse

  1. Recent (within the last 6 months)         Yes       No
  2. History                                       Yes       No

(b)    Abuse or misuse of prescription medication or herbal supplements

  1. Currently              Yes       No
  2. Recent (within the last 6 months)         Yes       No

(c)    History of non-compliance with prescribed medication

  1. Currently Yes       No
  2. Recent (within the last 6 months)         Yes       No

(d)    Describe misuse or abuse:       

 

6.* Risk factors for falls and injury. Identify any conditions about this resident that increase his/her risk of falling or injury (check all that apply):   orthostatic hypotension    osteoporosis    gait problem    impaired balance    confusion    Parkinsonism    foot deformity    pain    assistive devices   other (explain)

 

7.* Skin condition(s). Identify any history of or current ulcers, rashes, or skin tears with any standing treatment orders.

 

8.* Sensory impairments affecting functioning. (Check all that apply.)

(a) Hearing:          Left ear:             Adequate     Poor     Deaf    Uses corrective aid

Right ear:           Adequate     Poor     Deaf    Uses corrective aid

(b) Vision:     Adequate     Poor     Uses corrective lenses     Blind (check all that apply) –  R   L

(c) Temperature Sensitivity:            Normal   Decreased sensation to:   Heat   Cold

 

  1. Current Nutritional Status.        Height       inches             Weight       lbs.

(a) Any weight change (gain or loss) in the past 6 months?                                   Yes     No

(b) How much weight change?      lbs. in the past       months (check one)  Gain    Loss

(c) Monitoring necessary? (Check one.)                                                       Yes     No

If items (a), (b), or (c) are checked, explain how and at what frequency monitoring is to occur:

(d) Is there evidence of malnutrition or risk for undernutrition?                            Yes     No

(e)* Is there evidence of dehydration or a risk for dehydration?                 Yes     No

(f) Monitoring of nutrition or hydration status necessary?                                 Yes     No

If items (d) or (e) are checked, explain how and at what frequency monitoring is to occur:

(g) Does the resident have medical or dental conditions affecting: (Check all that apply)

Chewing    Swallowing    Eating    Pocketing food    Tube feeding

(h) Note any special therapeutic diet (e.g., sodium restricted, renal, calorie, or no concentrated sweets restricted):

(i) Modified consistency (e.g., pureed, mechanical soft, or thickened liquids):

(j) Is there a need for assistive devices with eating (If yes, check all that apply):            Yes     No

Weighted spoon or built up fork     Plate guard     Special cup/glass

(k) Monitoring necessary? (Check one.)                                                                 Yes     No

If items (g), (h), or (i) are checked, please explain how and at what frequency monitoring is to occur:

 

 

 

Resident Name         

Date of Birth             

Date Completed        

 

10.* Cognitive/Behavioral Status.

(a)*   Is there evidence of dementia? (Check one.)                                  Yes     No

(b)   Has the resident undergone an evaluation for dementia?                        Yes     No

(c)*   Diagnosis (cause(s) of dementia):   Alzheimer’s Disease    Multi-infarct/Vascular    Parkinson’s Disease    Other

(d)    Mini-Mental Status Exam (if tested)      Date         Score      

 

10(e)* Instructions for the following items: For each item, circle the appropriate level of frequency or intensity, depending on the item. Use the “Comments” column to provide any relevant details.

 

Item 10(e) A B* C* D* Comments
Cognition
I. Disorientation  Never  Occasional  Regular  Continuous
II. Impaired recall             (recent/distant events)  Never  Occasional  Regular  Continuous
III. Impaired judgment  Never  Occasional  Regular  Continuous
IV. Hallucinations  Never  Occasional  Regular  Continuous
V. Delusions  Never  Occasional  Regular  Continuous
Communication
VI. Receptive/expressive

aphasia

 Never  Occasional  Regular  Continuous
Mood and Emotions
 Never  Occasional  Regular  Continuous
VIII. Depression  Never  Occasional  Regular  Continuous
Behaviors
IX. Unsafe behaviors  Never  Occasional  Regular  Continuous
X.  Dangerous to self or

others

 Never  Occasional  Regular  Continuous
XI. Agitation (Describe behaviors in comments section)  Never  Occasional  Regular  Continuous

 

10(f) Health care decision-making capacity. Based on the preceding review of functional capabilities, physical and cognitive status, and limitations, indicate this resident’s highest level of ability to make health care decisions.

(a) Probably can make higher level decisions (such as whether to undergo or withdraw life-sustaining treatments that require understanding the nature, probable consequences, burdens, and risks of proposed treatment).

(b) Probably can make limited decisions that require simple understanding.

(c) Probably can express agreement with decisions proposed by someone else.

(d) Cannot effectively participate in any kind of health care decision-making.

 

11.* Ability to self-administer medications. Based on the preceding review of functional capabilities, physical and cognitive status, and limitations, rate this resident’s ability to take his/her own medications safely and appropriately.

(a) Independently without assistance

(b) Can do so with physical assistance, reminders, or supervision only

(c) Need to have medications administered by someone else

 

Print Name:      

Date:       

 

 

______________________________________

Signature of Health Care Practitioner

 

 

 

 

Resident Name         

Date of Birth             

Date Completed        

PRESCRIBER’S MEDICATION AND TREATMENT ORDERS AND OTHER INFORMATION

 

Allergies (list all):      

 

Note: Does resident require medications crushed or in liquid form? Indicate in 12(a) with medication order. If medication is not to be crushed please indicate.

 

12(a) Medication(s). Including PRN, OTC, herbal, & dietary supplements.

 

 

Include dosage route (p.o., etc.), frequency, duration (if limited).

12(b) All related diagnoses, problems, conditions.

 

 

Please include all diagnoses that are currently being treated by this medication.

12(c) Treatments (include frequency & any instructions about when to notify the physician).

 

Please link diagnosis, condition or problem as noted in prior sections.

12(d) Related testing or monitoring.

 

 

 

Include frequency & any instructions to notify physician.

                       
                       
                       
                       
                       
                       
                       
                       
                       

 

 

Prescriber’s Signature ___________________________________________                            Date          

 

Office Address                                                                                                                      Phone                  

 

 

 

 

Resident Name         

Date of Birth             

Date Completed        

PRESCRIBER’S MEDICATION AND TREATMENT ORDERS AND OTHER INFORMATION

 

Allergies (list all):      

 

Note: Does resident require medications crushed or in liquid form? Indicate in 12(a) with medication order. If medication is not to be crushed please indicate.

 

12(a) Medication(s). Including PRN, OTC, herbal, & dietary supplements.

 

 

Include dosage route (p.o., etc.), frequency, duration (if limited).

12(b) All related diagnoses, problems, conditions.

 

 

Please include all diagnoses that are currently being treated by this medication.

12(c) Treatments (include frequency & any instructions about when to notify the physician).

 

Please link diagnosis, condition or problem as noted in prior sections.

12(d) Related testing or monitoring.

 

 

 

Include frequency & any instructions to notify physician.

                       
                       
                       
                       
                       
                       
                       
                       
                       

 

 

Prescriber’s Signature ___________________________________________                            Date          

 

Office Address                                                                                                                      Phone                  

 

 

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