NURSING ASSESSMENT/REASSESSMENT

Client Last Name

Client First Name Date of Assessment

Client Date of Birth

Age FRA +1 if 65+ Male Female

Primary Diagnosis

Secondary Diagnosis

Tertiary Diagnosis FRA +1

Other Diagnoses

Diagnoses Known By Patient Family Primary Caregiver

Are Diagnoses Consistent with Last Assessment? Yes No (changes)

Recent Hospitalization(s)

Significant Medical/Surgical History

A

LLER

GIE

S

Assessed, No Allergies Reported (environmental, drug, food, or otherwise)

Allergies Reported

Penicillin Sulfa Medications Animal Dander Latex Dust Pollen

Bee Stings Milk/Dairy Products Nuts Eggs Other

Comments

Sees specialist for positive findings (name)

FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)

PH

YSI

CA

L

Eyes Assessed, No Problems Reported

Vision Issues FRA +1 Left Right

Glaucoma Cataracts Macular Degeneration Legally Blind

Glasses/Corrective Lenses Distance Reading

Ears Assessed, No Problems Reported

Auditory Issues

Hard of Hearing Deaf Discharge Hearing Aid

Nose & Sinus Assessed, No Problems Reported

Nasal Issues Left Right

Epistaxis Drainage Congestion

Loss of Smell Sinus Problems

Neck & Throat Assessed, No Problems Reported Otolaryngology Issues Hoarseness Sore Throat Lesions

Oral Assessed, No Problems Reported

Oral Issues Upper Lower

Dentures Partial Bridge

Difficulty Chewing/Swallowing Episodes of Choking Other

Mobility No Problems Reported

Mobility Issued Reported

Uses Equipment (see below) Requires Supervision Fall Within 3 Months FRA +1

Comments

Sees specialist for positive findings (name)

FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)

Nursing Reassessment (4/16) Page 1 of 8 FRA Page Tally: _____

NY Non-Waiver Patient Onboarding Kit 9/17

Client Initials

Nursing Reassessment (4/16) Page 2 of 8 FRA Page Tally: _____

EQU

IPM

ENT

Assessed, No Equipment in Home

Equipment in Home

Walker Cane Wheelchair Hospital Bed Lift

Commode Shower Bench/Chair Raised Toilet Seat Grab Bars

Nebulizer Medication Box PERS Other

Was equipment management reviewed? Yes No

Comments

FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)

V

ITA

L SI

GN

S

Blood Pressure / Lying Sitting Standing Pulse Regular Irregular Respirations /min Regular Irregular Labored Temperature Orally Rectally Axillary Comments

FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)

N

UTR

ITIO

NA

L &

DIE

TA

RY

INT

AK

E

Appetite

Diet Fluids

Quantity Restrictions per day Non-Compliant with Diet/Fluids/Restriction

GT Feeds times daily Dietary Supplements Type Amount per day

Weight lbs As Reported by Client Client Scale Approximate, Unable to Weigh

Recent Change Increase lbs in months Decrease lbs in months

Height As Reported by Client

Nutritional Risk Screen (“NRS”)

Has an illness or condition that necessitates a special diet NRS +1

Eats fewer than 2 meals per day NRS +1

Eats only a few fruits, vegetables, or milk products NRS +1

Has 3 or more drinks of alcohol daily NRS +1

Has teeth or mouth problems making eating difficult NRS +1

Does not have enough money to purchase food NRS +1

Eats alone most of the time NRS +1

Takes 3 or more prescribed or OTC drugs per day NRS +1

Unintentionally lost or gained 10 lbs in the last 6 months NRS +1

Not always able to shop, cook, and/or feed self NRS +1

NSR TOTAL:

NRS total equals 10 so client is considered high risk – REFER FOR MD FOLLOW UP –

Comments

Sees specialist for positive findings (name)

FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)

NY Non-Waiver Patient Onboarding Kit 9/17

Client Initials

Nursing Reassessment (4/16) Page 3 of 8 FRA Page Tally: _____

C

AR

DIO

PU

LMO

NA

RY

Assessed, No Problems Reported

Cardiovascular Issues

History HTN CHF MI CAD Bypass Stent High Cholesterol Angina

Current Dyspnea on Exertion Fatigues Easily Syncope

Lower Extremity Edema Pitting Non-Pitting

Chest Pain Angina associated with Activity Sweats SOB

Frequency/Duration Relief

Pacemaker MD Following/Checking

Comments

Sees specialist (e.g., Cardiologist) for positive findings (name)

FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)

M

USC

ULO

SKEL

ETA

L &

NE

UR

OLO

GIC

AL

Musculoskeletal

Assessed, No Problems Reported

Musculoskeletal Issues FRA +1

History Osteoarthritis Rheumatoid Arthritis Joint Replacement

Current Tremor Cramps Weakness Stiffness Limited ROM

Decreased Coordination Decreased Muscle Strength Unsteady Gait

Swelling Deformity Contractures

Paralysis/Paresis side Other

Neurological

Assessed, No Problems Reported

Neurological Issues FRA +1

History Seizures Syncope CVA TIAs Parkinson’s

Current Numbness Unequal Grasp Headaches Poor Balance Dizziness

Seizures (type/last occurrence) Other

Comments

Sees specialist (e.g., Neurologist) for positive findings (name)

FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)

R

ESP

IRA

TO

RY

Assessed, No Problems Reported

Breathing Issues

History Asthma Bronchitis Cancer Pneumonia COPD TB

Sleep Apnea CPAP BiPAP Vendor

Current Sounds Diminished Rales Rhonchi Crackles Wheezing

Pursed Lips Breathing Dyspnea on Exertion Nasal Flaring SOB

Inhaler Nebulizer Cough Productive Dry

Vent Settings Type

Frequency Checked By

Trach Size Brand

O2 Use Type Flow liters/min Backup Tank

Frequency Continuous PRN Night Other

Via Nasal Prongs Mask Trach Vent

Comments

Sees specialist for positive findings (name)

FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)

NY Non-Waiver Patient Onboarding Kit 9/17

Client Initials

Nursing Reassessment (4/16) Page 4 of 8 FRA Page Tally: _____

R

EPR

OD

UC

TIV

E

Assessed, No Problems Reported

Issues with Reproductive Organs

History Cancer (type) Hysterectomy Mastectomy BPH TURP

Current Discharge/Drainage Inflammation Cysts Lesion/Mass

Preventive OB/GYN Care Pregnant

Comments

Sees specialist for positive findings (name)

The above is different from the previous assessment conducted (differences) A

BD

OM

EN/G

AST

RO

INTE

STIN

AL

Assessed, No Problems Reported

Abdominal/Gastrointestinal Issues

History Cancer Colitis Ulcers Diverticulitis Polyps GERD

Gallbladder Disease/Surgery GI Bleed

Current Distention Hernia Ascites (girth) cm

Tenderness Palpable Mass Hypoactive Sounds Hyperactive Sounds

Nausea Vomiting Frequency Amount

Indigestion Cramps Flatulence Heartburn Bleeding

Hemorrhoids Internal External

Ostomy (type) Excoriated Stoma Appliance

Comments

Sees specialist for positive findings (name)

FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)

EL

IMIN

ATI

ON

Bowel Last BM (date) Usual Bowel Frequency per day

Assessed, No Problems Reported

Bowel Issues

Diarrhea Acute Occasional per day Chronic

Constipation Acute Occasional per day Chronic

Incontinent FRA +1 Always Occasional

Impacted Laxative and/or Enema Use (regimen)

Recent Change Abnormal Stool

Genitourinary

Assessed, No Problems Reported

Genitourinary Issues

History Recurrent UTIs Renal Failure Cancer Nephrostomy

Current No Problems Reported

Urinary Issues

Frequency Burning Urgency Hematuria Nocturia

Incontinent FRA +1 Always Occasional Day Night

Diapers Pads

Dialysis Hemodialysis Peritoneal Su M Tu W Th F Sa

Catheter Indwelling Suprapubic External Straight

Size Frequency Last

Responsible Party

Comments

Sees specialist for positive findings (name)

FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)

NY Non-Waiver Patient Onboarding Kit 9/17

Client Initials

Nursing Reassessment (4/16) Page 5 of 8 FRA Page Tally: _____

END

OC

RIN

E &

HEM

ATO

PO

IETI

C

Assessed, No Problems Reported

Endocrine/Hematopoietic

Thyroid Issue Heat/Cold Intolerance Excessive Bleeding

Anemia Pernicious Iron Deficiency 2 Bleed Other

Diabetes Type 2 (NIDDM)

Type 1 (IDDM) Present Blood Glucose Result mg/dl

Random Blood Sugar (time tested)

Usual Range mg/dl

Frequency Checking/Managing

Person Responsible for Checking

Uses Insulin Self-Administers Administered by

Needs Instruction on Glucose Monitoring Non-Compliant with Glucose Monitoring

Comments

Sees specialist for positive findings (name)

Feet checked by Podiatrist

FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)

EM

OTI

ON

AL/

BEH

AV

IOR

AL

Consciousness Alert Lethargic Nonresponsive

Orientation Person Place Time

Cognition Comprehension Impaired/Decreased (e.g., confused, impulsive, memory deficits) FRA +1

Mood Calm Angry Anxious Agitated

Depressed Withdrawn Fearful

Behavior Appropriate Non-compliant Wanders Indifferent

Hostile Suspicious Verbally Abusive Physically Abusive

Perception Appropriate Hallucinations

Sleep/Rest No Problems Insomnia Disturbance(s) Uses Sleep Aid

Comments

Behavioral health needs are managed? Yes No Referral for Psych Indicated

Sees specialist for positive findings (name)

FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)

M

EDIC

ATI

ON

MA

NA

GEM

ENT

Assessed, No Medications Reported

Medication(s) Taken (Complete Medication Profile and assess the following)

Four or more prescriptions taken (any type)? Yes No

Does client report compliance with medications? Always Sometimes Never

Does the supply at hand reflect compliance? Yes No

Would the client benefit from a medication box? Yes No

Do any medications require pre-pour/administration? Yes No

If yes, name and relationship of responsible person

Does this person need instruction? Yes No

Are there any diagnoses without a corresponding medication? Yes No

If yes, explanation

Are there any medications without a corresponding diagnosis? Yes No

If yes, explanation

Comments

Sees specialist for positive findings (name)

FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)

NY Non-Waiver Patient Onboarding Kit 9/17

Client Initials

Nursing Reassessment (4/16) Page 6 of 8 FRA Page Tally: _____

PA

IN

Assessed, No Pain Reported

Pain Location Onset/Duration

Level/Intensity

Ache Prick Throbbing Burning Sharp

Shooting Dull Pulling Other

Is pain impacting level of function? Yes FRA +1 No

What is the current pain regimen?

Is current pain regimen effective? Yes No (reason)

Comments

Sees specialist for positive findings (name)

FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)

SK

IN

Assessed, No Problems Reported

Dermatologic Issues

History Decubitis Venous Stasis Ulcer Cellulitis Diabetic Ulcer

PVD Slow/Poorly Healing Wound(s)

Current Bruises Scabs Burns Abrasions Lesions

Cellulitis Lacerations Fistula Stoma Keloids

Scars Rash Flushed Parlor Jaundiced

Cyanotic Incision Ashen Dry/Flaky Scaly

Pruritus Erythema Petechiae Decubiti/Wound

Indicate any identifying marks, scars, amputated limbs, and/or wounds/ulcers/lesions/rashes requiring care on the body below:

Comments

Name of individual managing would care, if applicable

Sees specialist for positive findings (name)

FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)

NY Non-Waiver Patient Onboarding Kit 9/17

Client Initials

Nursing Reassessment (4/16) Page 7 of 8 FRA Page Tally: _____

IMM

UN

IZA

TIO

N

None Refused, Education Provided

Pneumonia (date) Influenza (date) Hepatitis B (date)

Tetanus (date) Other (date)

Comments

Sees specialist for positive findings (name)

FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)

H

OM

E SA

FET

Y

Supplies, Equipment, Electrical

Extension cord properly used? Yes No N/A

All electrical medical equipment properly grounded? Yes No N/A

Electrical cords and telephone cords safely positioned and in good repair? Yes No N/A

Electrical appliances away from tub/shower? Yes No N/A

Medications stored in safe appropriate place? Yes No N/A

Outdated medications discarded? Yes No N/A

Storage/handling of oxygen and other supplies safe and appropriate? Yes No N/A

Proper storage of hazardous materials? Yes No N/A

Proper storage or handling of food? Yes No N/A

Home Environment FRA +1 If One or More No’s

Skid resistant mats in place? Yes No N/A

Grab bars, tub bench in place? Yes No N/A

Adequate heat/cooling ventilation and light? Yes No N/A

Scatter rugs secured? Yes No N/A

Appropriate footwear? Yes No N/A

Adequate space for care? Yes No N/A

Rooms free from clutter and objects (including pets) that impair mobility? Yes No N/A

Fire/Emergency

Smoke detectors present and working on each level of the home? Yes No N/A

Knowledgeable in accessing emergency assistance? Yes No N/A

Planned escape route from all rooms of the home? Yes No N/A

Smoking safety guidelines followed? Yes No N/A

Has emergency preparedness kit and/or extra medications/supplies? Yes No N/A

Has emergency plan in event of disruption of services? Yes No N/A

Comments

FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)

FA

LL R

ISK

ASS

ESSM

NT

Fall Risk Assessment Score (FRA total)

FRA total is greater or equal to 5 so client is considered high risk Falls Precaution Sheet Completed

Comments

Sees specialist for positive findings (name)

FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)

NY Non-Waiver Patient Onboarding Kit 9/17

Client Initials

Nursing Reassessment (4/16) Page 8 of 8 FRA Page Tally: _____

EM

ERG

ENC

Y P

REP

AR

EDN

ESS

Priority Code (Select one. Must be determined by clinician, independent of service hours)

Level 1 High Priority – Requires uninterrupted service(s)/must have care. In case of disaster, every possible effort must be made to provide service(s) to client

Level 2 Moderate Priority – Services may be postponed with telephone contact. A caregiver can provide basic care until the emergency situation improves

Level 3 Low Priority – May be stable and has access to informal supports. Client can safely miss a scheduled visit

Transportation Assistance Level (Select one. Indicates transportation needs during planned regional/statewide evacuation) TAL 1 Non-Ambulatory – Requires transport by stretcher

TAL 2 Wheelchair-Bound – Unable to walk due to physical and/or medical condition

TAL 3 Ambulatory – Able to walk without physical assistance

Flood Zone (if known)

Comments

FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)

Based upon this assessment (including diagnoses and medication profile), the following precautions should be entered on the Form CMS-485 and aide plan of care (in addition to Standard/Universal):

Bleeding Skin Hypo/Hyperglycemia Seizure Sharps Aspiration Falls Oxygen

Patient has verified that the following Primary Care Provider information is accurate:

Name: Address: Telephone #:

Significant needs/conditions/changes were observed that might be addressed through palliative care

If palliative care is indicated, I have provided related information/facilitated access to consultation

Additional Narrative Notes

Plan of Care discussed with client/caregiver? Yes No (reason)

Signature

Print Name & Title Date

NY Non-Waiver Patient Onboarding Kit 9/17