admin@carenationagency.com
(856) 460-CARE (2273)
(908) 774-CARE (2273)
FAX: (856) 494-1530
Facebook-f
Instagram
Google
Linkedin-in
Quick Inquiry
Home
About
Services
Personal Care Services
Daily Living Assistance
Transportation Services
Home Health Aide Services
Physical Therapy
Occupational Therapy
Veteran Affairs (VA) Home Care
Pediatric Home Care
Developmental Disabilities (DDD) Support
Skilled Nursing
Blogs
Careers
Forms
CNA – Intake Form
CNA – Forms – Client Medical Assessment
CNA-HR-Employment Application Form
Employer Reference Request
Service Areas
Contact
Home
About
Services
Personal Care Services
Daily Living Assistance
Transportation Services
Home Health Aide Services
Physical Therapy
Occupational Therapy
Veteran Affairs (VA) Home Care
Pediatric Home Care
Developmental Disabilities (DDD) Support
Skilled Nursing
Blogs
Careers
Forms
CNA – Intake Form
CNA – Forms – Client Medical Assessment
CNA-HR-Employment Application Form
Employer Reference Request
Service Areas
Contact
Schedule Appointment
Medical Assessment Form
Assessor
Date
MM slash DD slash YYYY
Time
Hours
:
Minutes
AM
PM
AM/PM
Personal Information
Clients Name:
Age:
Date of birth:
MM slash DD slash YYYY
Medical Assessment:
Primary Diagnoses:
Secondary diagnoses:
Relevant medical / surgical information:
Date
MM slash DD slash YYYY
Condition
Details of Treatment
Allergies/Sensitivities:
Skin Condition:
Intact
Redness
Decubitus ulcer
Excoriation
Diabetic:
Insulin
Oral hypoglycemic
Diet controlled
Mental Status/Behavior:
Orientation:
Time
Hours
:
Minutes
AM
PM
AM/PM
Place
Personal
Comments
Progressive Disorientation
Transient Disorientation
Behaviour:
Compliant to care
Anxious
Restless
Agitated
Aggression:
Verbal
Physical
Sexual
Inappropriateness:
Verbal
Social
Sexual
Abuse:
History of being abused
History of being abusive
Risks:
Elopement
Falls
Aggression
Choking
Functional Status:
Transferring:
Self
Assist
Total care
Appetite:
Good
Fair
Poor
Meal Prep
Self
Assist
Total care
Housework:
Self
Assist
Total care
Feeding:
Self
Assist
Total care
Bathing:
Self
Assist
Bed
Appetite:
Good
Fair
Poor
Toiletting:
Self
Assist
Incontinent
Bladder
Bowel
Notes:
Activity:
Mobility
Independent
Bedridden
Assistance Required
Assistive Devices:
Mechanical Lifts
Walker
Cane
Crutches
Wheelchair
Other
Assistive Devices:
Prosthetics
Leg Brace
Neck Brace
Hearing Aid
Other
Limbs:
Upper Limbs
Normal
Impairment ( R / L )
Tremor ( R / L )
Amputation ( R / L )
Prosthesis
Lower Limbs
Normal
Impairment ( R / L )
Tremor ( R / L )
Amputation ( R / L )
Prosthesis
Notes:
Nutrition:
Nutritional Status:
Height
Weight
Date
MM slash DD slash YYYY
Mouth:
Own Teeth
Partial
Dentures ( Up / Low )
No Teeth
Ulcers
Infection
Drooling
Feeding:
Independent
Supervision
Assistance
Total Feed
Choking Problem
Swallowing Problem
Diet:
Supplement:
Notes:
Elimination:
Bladder:
Continent
Incontinent
Nocturia
Indwelling Catheter
In & Out Catheterization
Ileoconduit
Condom Drainage
Type and Size
Insertion Date
Appliance de to be changed
Bowels:
Continent
Incontinent
Constipation
Diarrhea
Self Care
Assist
Total Care
C. Difficile
Ostomy Care/Ostomy Type
Date to be changed
Mushroom Catheter Date Inserted
Type and Size
Ostomy Care/Ostomy Type
Date to be changed
Mushroom Catheter Date Inserted
Type and Size
Notes:
Medications:
Medication
Dosage
Frequency
Comments
Medication
Dosage
Frequency
Comments
Medication
Dosage
Frequency
Comments
Additional Information/Treatments:
Fall Risk Assessment
INSTRUCTIONS:
Assess the resident status in the eight clinical condition parameters listed (A-H) by assigning the corresponding score which best describes the resident in the appropriate assessment column. Add the column of numbers to obtain the TOTAL SCORE.
If the total score is 10 or more, the resident may be considered at HIGH RISK for potential falls.
An intervention should be initiated immediately and documented on the care/service plan.
A
Level of Consciousness/ Mental Status
ALERT – (oriented x 3) or COMATOSE
1
2
3
4
DISORIENTED x 3 at all times
1
2
3
4
INTERMITTENT CONFUSION
1
2
3
4
B
History of Falls (past 3 months
NO FALLS in the past 3 months
1
2
3
4
1-2 FALLS in past 3 months
1
2
3
4
3 OR MORE FALLS in past 3 months
1
2
3
4
C
Ambulatory & Elimination Status
AMBULATORY/CONTINENT
1
2
3
4
CHAIR BOUND – may require assistance with elimination
1
2
3
4
AMBULATORY/INCONTINENT
1
2
3
4
D
Vision Status
ADEQUATE (with or without glasses)
1
2
3
4
POOR (with or without glasses)
1
2
3
4
LEGALLY BLIND
1
2
3
4
E
Gait/Balance If total is greater than 1 – refer to Rehab Dept. for screening
To assess the resident’s Gait/Balance, have him/her stand on both feet without holding onto anything; walk straight forward; walk through a doorway; make a turn.
GAIT/BALANCE normal
1
2
3
4
Balance problem while standing
1
2
3
4
Balance problem while walking
1
2
3
4
Decreased muscular coordination
1
2
3
4
Change in gait pattern while walking through doorway
1
2
3
4
Jerking or unstable when making turns
1
2
3
4
Requires use of assistive devices (i.e., cane, w/c, walker, furniture)
1
2
3
4
F
Systolic Blood Pressure
NO NOTED DROP between lying and standing
1
2
3
4
Drop LESS THAN 20mm Hg between lying and standing
1
2
3
4
Drop MORE THAN 20 mm Hg between lying and standing
1
2
3
4
G
Medications If total is greater than 2 – refer to physician or pharmacy consultant for assessment.
Respond below based on the following types of medications: Anesthetics, Antihistamines, Antihypertensives, Antiseizures, Benzodiazepines, Cathartics, Diuretics, Hypoglycemics, Narcotics, Psychotropics, Sedatives/Hypnotics.
NONE of these medications taken currently or within past 7 days
1
2
3
4
TAKES 1-2 of these meds currently and/or within past 7 days
1
2
3
4
TAKES 3-4 of these meds currently and/or within past 7 days
1
2
3
4
If resident has had a change in medication and/or change in dosage in the past 5 days – score 1 additional point
1
2
3
4
H
Predisposing Conditions or Diseases
Respond below based on the following predisposing conditions: Hypotension, Vertigo, CVA, Parkinson’s, Loss of Limb(s), Arthritis, Osteoporosis, Fractures.
NONE PRESENT
1
2
3
4
1-2 PRESENT
1
2
3
4
3 OR MORE PRESENT
1
2
3
4
ASSESSMENT 1
SIGNATURE/TITLE
Date
MM slash DD slash YYYY
ASSESSMENT 2
SIGNATURE/TITLE
Date
MM slash DD slash YYYY
ASSESSMENT 3
SIGNATURE/TITLE
Date
MM slash DD slash YYYY
ASSESSMENT 4
SIGNATURE/TITLE
Date
MM slash DD slash YYYY
RESIDENT NAME:
Client or Guardian Authorization
The information contained within this document is not shared with any third parties. The information is kept in the client’s home file and the company’s client file for as long as services are being rendered. Upon termination of services the document is destroyed in a timely manner or retained if required by law. The document is used as a guide and reference to essential client care information. The Client or Legal Guardian, by signing this document gives the company consent to collect the information contained herein and use for the specified purpose.
Signed
Date
MM slash DD slash YYYY
Quick Inquiry
Name
(Required)
Phone
(Required)
Email
(Required)
Message Us:
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.
Schedule Consultation
Name
(Required)
Phone
(Required)
Email
(Required)
Best Time to Call
Morning
Afternoon
Evening
Message Us:
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.
