Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Time
Name/Label
ID Band in Place
Preferred Language: English Other________________________ Interpreter Offered: Name ____________________________ Declined Interpreter Services
Information Obtained: Patient
Significant Other
Advanced Directive Health Care Proxy: On File Information Given Name of proxy ______________________________________________ PCP_________________________
CHIEF COMPLAINT / REASON FOR ADMISSION / PLANNED PROCEDURE:
VITAL SIGNS
RR
PAIN LEVEL
Current: _____ / 10
Max _____ / 10
BP
Unconscious Patient Assess & document behaviors & physiologic changes consistent with pain.
02SAT
Weight (kg)
Height
Onset ________________________________________________________________
Location______________________________________________________________
Duration______________________________________________________________
Characteristics_________________________________________________________
Aggravating___________________________________________________________
Relieved______________________________________________________________
Treatment_____________________________________________________________
PROBLEMS: YES NO
ALLERGIES
No Known Allergies
Reaction Codes: (1) Anaphylactic reactions (2) Breathing problems (3) ENT swelling (4) Mental changes (5) GI disturbances (6) Skin reactions
Severity Codes: (M) Mild (MO) Moderate (S) Severe
Allergy/Intolerance
Reaction & Severity Codes
Allergy/Intolerance
Reaction & Severity Codes
Shellfish
Iodine
IV Contrast
Latex
No Known Allergies
No history
Hypertension
MI/Angina
Metabolic/Endocrine
No history
Diabetes
Cardiac disease
Heart Failure
Pacemaker
Defibrillator
Psychiatric Illness
No history
Depression Anxiety
Cardiac surgery
Valve replacement
VAD
Other
Musculoskeletal
No history
Joint replacement
Arthritis
Other
Respiratory
No history
COPD
Tuberculosis
Pneumonia
Asthma
Sleep apnea
Other
Cancer
No history
No history
PVD
GI/GU/GYN
No history
Hepatitis
GYN problems
Kidney Stones
GI Bleed
Pancreatitis
GU problems
Surgery
Kidney Disease
GERD
Other
Prostate
Anesthesia Problems
Neurologic
No history
Dementia
Migraines
Comments:
Seizures
Other
Vision/Hearing Problems
EENT
CVA
Cataracts
Other
Other
History of falls
LMP_______________
Thyroid disease
Dose
Frequency
Medication
Dose
Taking no medications
Frequency
Signature:
Z:nadmin/Assessment Forms/Adult Assessment Outpatient ACU Prescreening 04/16/04 , 06/28/04, 101904 ; 10/11/05 MR# 2002-015
Page 1 of 2
NAME:
MEDICAL RECORD #:
PROBLEMS: YES NO
FUNCTIONAL SCREEN
PT Orthopedic Surgery
OT ________________________________________________
PT Crutches/Walker
Speech ____________________________________________
PT Other
NUTRITIONAL ASSESSMENT
NPO Since _______________________
PROBLEMS: YES NO
NUTRITION REFERRAL
Date / Time Notified: _________
MENTAL STATUS
Alert
Disoriented
Unconscious
Developmentally Delayed
Oriented
Confused
Combative
Other
Does the patient demonstrate present behaviors and or have a past medical history that puts him/her at risk for
Harming self and/or others? Yes No If yes, ask the patient to describe techniques, methods and/or tools that
have helped to de-escalate behaviors. __________________________________________________________________
PROBLEMS: YES NO
LEARNING ASSESSMENT
1. Readiness to Learn
3. Barriers to Learning
PROBLEMS: YES NO
High
Reading
Communication Deficit
Language
Memory deficit
Patient
Disease
Medications
Diet
Other
Check in
function
Medium
Listening
Literacy
Hearing/Visual
Family
Poor
Demonstration
Psychosocial/Anxiety
Other None
Patient
Treatment
Pain Management
Equipment
Surgery
Family
ABUSE ASSESSMENT
PROBLEMS: YES NO
S
OCIAL
WORKER REFERRAL
1. Do you feel safe at home? Yes SW No
If No, Why Not? ___________________________
2. Have you been hurt physically, verbally, emotionally, sexually, or financially exploited by someone within the past year? Date / Time Notified:_____________
SW Yes No Please explain. _____________________________________
3. Would you like to discuss this with a member of our staff? SW Yes No
Domestic Violence Notice Given Yes
VALUE ASSESSMENT
Is there any conflict between your religious/cultural beliefs that are in conflict with your medical treatment? Yes No
Religion:
PROBLEMS: YES NO
PROBLEMS: YES NO
LIVING
SITUATION
SUPPORT
SYSTEMS
Alone
CM
Assisted Living
CM
Elder Services/VNA
SW
Homeless
With Family/Friends
CM
Nursing Home
CM
Group home
CM
History of falls
Other
Escort Home:
Friends
Involved family
Uninvolved family
SW None
Other
ADDITIONAL NOTES: __________________________________________________________________________________________________________________
Neighbors
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
_____________________________________________________________________________________________PreScreen
Date:
Time:
ing RN:
Z: nadmin/Assessment Forms/Adult Assessment Outpatient ACU,Prescreening 04/16/04 , 06/28/04, 101904
MR# 2002-015
Page 2 of 2