NURSING ASSESSMENT - Intranet

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NURSING ASSESSMENT

Consumer Name:

DOB: AGE: GENDER: Male Female

LEGAL STATUS: Minor Adult w/Guardian Adult w/o Guardian

TextCONTACT TYPE (Check all that apply):

Face to Face Telephone Consumer Collateral (family members or othe health care providers)

VITAL SIGNS:Wt: BMI:

Temp: BP: Pulse: Respirations:

Text SOURCE(S) OF INFORMATION (Check all that apply):See Section 1 of the consumer's record for current demographic and emergency contact information.

Consumer Legal Guardian/Caregiver MHMRA Chart School Records Hospital RecordOther:

DATE ILLNESS / SURGERY

Significant pastMedical and or

Surgical History

HOSPITALIZATION (S) WITHIN THE PAST YEAR NO YES (if yes, please list):

Admit/Discharge Date Name of Hospital Reason for Hospitalization

Ht:VITAL SIGNS:

PRIMARY CARE PHYSICIANAddressName Phone

PhoneAddressName/SpecialtyCURRENT SPECIALTY PHYSICIAN(S) / CLINIC(S)

REC-MR: 023 (8/11)

Case #: Unit:

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Bruise

Consumer Name:

PhoneAddressName/SpecialtyCURRENT COUNSELING/THERAPY

ALLERGIES: (Food/Medications):

TextCURRENT MEDICATIONS

Include prescription, over-the-counter, vitamins, minerals, and herbal supplements)FOR ADDITIONAL MEDICATIONS SEE ATTACHED MEDICATION ADDENDUM

TextMEDICAL HISTORY

SeizureDisorder Nausea Asthma Pain Hypothyroidism

Skin (specify location):

Head Injury

Dizziness

Headaches

Vomiting

Diarrhea

Constipation

Cough(unproductive)

Cough(productive)Sortness of

breath

Location

Duration

Intensity

Heart Disease

Hyperthyroidism

NIDDM

SlurredSpeech

Indigestion(GERD) IDDM

Other respiratoryproblems

Intact

Abrasion

Rash

LacerationSwelling

Hypertension

Date of last menstrual period: Difficult menstral periods: No Yes (If yes, describe)

HISTORY OF STDS: Yes (If yes, check all that appy)No

Chlamydia Syphilis Genital Wars (HPV) Gonorrhea Other:

HISTORY OF OTHER COMMUNICABLE DISEASE: Yes (If yes, check all that appy)No

Date of last TB Skin Test and results:

ChickenpoxDate Date

TuberculosisDate

Date of last Chest X-Ray

DateMeningitis

DateA Date

OtherHepatitis (check one)B C Enter disease type

Enter disease type Date

Other

Enter disease type Date

Other

Case #:

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Consumer Name:

IMMUNIZATION HISTORY (Check all that apply):

DatePneumonia

DateInfluenza

DateTetanus

DateHepatitis A

DateHepatitis B

DateOther

(For school age consumers, obtain a copy of the current immunization records.)

GROOMING:Appropriate to ageInappropriate to age

Bizarre

ENGAGEABILITY:Cooperative Uncooperative Suspicious Hostile

DisheveledPoor hygieneWell groomed

Unengageable SeductiveGuarded Aggressive

TextMENTAL STATUS EXAMINATION

Comments:

TicsRestless

TremorsFidgety

AgitatedCalm

MOTOR ACTIVITY:

AngryAnxious

FearfulSad

IrritableEuthymic

MOOD:

RepetitiveBehavior

Hypoactive

FlatConstricted

TearfulAppropriateAFFECT:

DepressedElevated

LabileBlunt

Loose AssociationsGoal Directed

THOUGHT PROCESS:

Comments:

Comments:

Comments:

Appropriate to Age Flight of IdeasMinimizingTangential

EvasiveLogical Absent (If present, check all that apply)

ObsessionsIllusionsThought Insertion/withdrawalDelusionsUnable to communicatePresent

THOUGHT CONTENT:

Comments:

CommandUnable to communicate

Absent (If present, check all that apply)PresentTHOUGHT CONTENT:

Auditory Visual OlfactoryComments:

Comments:

Not presentPresent w Plan/MeansPresent w Plan only

Absent (If present, check all that apply)PresentTHOUGHT CONTENT:

Homicidal Ideation:

Case #:

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Consumer Name:

Comments:

PlaceTimeIntact

ORIENTATION:

Person

Yes No (If no, check all that apply)

CONCENTRATION:ImpairedIntact

SUICIDAL HISTORY:Absent (If present, check all that apply)Present

MEMORY:YesIntact

JUDGMENT / INSIGHT:

FairAdequate for age and situation

SPEECH:

PoorLimited

Suicidal Ideation:

Present w Plan/MeansPresent w Plan onlyINot Present

Comments:

No (If no, check all that apply)

ImmediateRecentRemote

Other (specify)SpontaneousAppropriate to ageAdequate (vol./rate/tone)

ExcessivePressuredDelayed

Comments:

Comments:

Behavioral history as reported by: CG = Caregiver C = Consumer D = Documentation (behaviors obtained from documentation)DestructiveCombativeImpulsive

ObsessiveOppositionalAggressive

BEHAVIOR HISTORY

RestlessCompulsive

HyperactiveIntrusiveAngry

IrritableHostileArgumentative

CGCGCGCGCGCGCGCGCGCGCGCGCGCG

C

CC

CCCCCCCCCCC

D

DD

DDDDDDDDDDD

CG

DCDCDCDCDCDCDCDCDCDCDD

CC

CGCGCG

CGCGCGCGCGCGCGCG

Irritable

AngryIntrusiveHyperactive

CompulsiveRestlessAggressiveOppositionalObsessive

ImpulsiveCombativeDestructive

Comments:

Case #:

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Consumer Name:

CaneHearing Aid(s)Wheel ChairNone needed

SPECIAL EQUIPMENT: (check all that apply)

CrutchesPhysical assistanceSupervisionIndependent

WALKING:

ProsthesisGlassesHelmet

Adequate for age and situation EATING:Physical assistance

Verbal promptingSupervisionIndependent

Non-VerbalGestures

Feeding equipment

Verbal promptingSupervision

GROOMING:Independent

Supervision

BATHING:Independent

Physical assistanceVerbal prompting

SupervisionIndependent

Physical assistance Physical assistanceVerbal prompting

VocalizesVerbal

TOILETING: COMMUNICATION:

Verbal prompting Supervision

FUNCTIONAL SCREEN

Physical AssistanceIndependent

DRESSING:

Comments:

MEDICATION ADDENDUM

ADDITIONAL COMMENTS AND/OR OBSERVATIONS

DatePrinted Name/Credentials

RN Signature

Case #:

Time Time

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(Printed name/title)

Consumer Name:

Nursing Plan of Care

1.2.3.4.5.

3.2.1.

5.4.

GOALS:

5.4.3.2.1.

InitialDirect care staff will receive the following training by a licensed nurse:

3.2.1.

3.2.1.

InitialRN delegation of the following tasks will be made to non-licensed staff (See attached Delegation Process Forms):

Other recommendations (check one) Yes (If yes, document below):No

RN Completeing Form:

RN Signature: Date:

Case #:

NURSING ASSESSMENT - Intranet

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