Nursing Assessment for Home Care Page 1 of 3

Patient Information:
Last Nam e: First Nam e: Middle Initial:

ADAP ID Num ber: 555- Social Security Num ber:

Contact Person (Nam e & Relationship):

Contact Phone (Day-tim e): Please submit release to allow Program contact.

Living Situation:
Dwelling: ‘ Apartm ent ‘ House ‘ Other: Floor: # of Room s: Elevator: ‘ Yes ‘ No

Lives alone: ‘ Yes ‘ No Identify all individuals living in the hom e:

List the services, hours and days they are available and able to assist with care giving:

Hospitalization:
Hospital Nam e: Address:

Hospitalized: From : To: Diagnoses:

Hospital Contact: Phone:

Patient Status:
Is patient alert? ‘ Always Can patient direct a hom e care worker? ‘ Yes ‘ No
‘ Som etim es If no, who is responsible for directing home care workers?
‘ Never Nam e/Relationship:

Patient Height: Patient W eight:

Recent significant weight loss? ‘ Yes ‘ No If Yes, am ount lost:

Impairments:
Sensory: Muscular/Motor:

None Partial Total None Partial Total

1. Speech ‘ ‘ ‘ 1. Hand/Arm ‘ ‘ ‘
2. Sight ‘ ‘ ‘ 2. Upper Extrem ities ‘ ‘ ‘
3. Hearing ‘ ‘ ‘ 3. Lower Extrem ities ‘ ‘ ‘

Cardiovascular / Respiratory:
None Partial Total Describe im pact on functional ability.

1. Respiratory ‘ ‘ ‘ ________________________________________________
2. Cardiac ‘ ‘ ‘ ________________________________________________
3. Circulatory ‘ ‘ ‘

1. Does patient have history of tuberculosis? ‘ Yes ‘ No ‘ Pulm onary ‘ Extra pulm onary
2. Did patient com plete therapy? ‘ Yes ‘ No
3. Does patient currently have tuberculosis? ‘ Yes ‘ No ‘ Pulm onary ‘ Extra pulm onary
4. Is patient currently on tuberculosis prophylaxis? ‘ Yes ‘ No Hx of TB prophylaxis ‘ Yes ‘ No
5. Last docum ented PPD: Date and result ________________ Anergy results if available:____________________
6. If on tuberculosis treatm ent, are there 3 negative AFB? ‘ Yes ‘ No Negative chest x-ray ‘ Yes ‘ No
New York State Department of Health
Uninsured Care Programs Nursing Assessment - Page 2 of 3

Patient Name:______________________________________________________ ADAP ID#: 555-_________________

Agency: ___________________________________________________________ Provider Num ber: ______________

Mental Status

Never Partial Total Never Partial Total

1. Oriented place and tim e ‘ ‘ ‘ 8. Danger to: Others (Aggressive) ‘ ‘ ‘

2. Anxiety ‘ ‘ ‘ Self ‘ ‘ ‘
3. Agitated ‘ ‘ ‘ 9. Articulates needs ‘ ‘ ‘
4. Short term m em ory loss ‘ ‘ ‘ 10. Sleep disorder ‘ ‘ ‘
5. W anders ‘ ‘ ‘ 11. Abusive to: Others ‘ ‘ ‘
6, Depression ‘ ‘ ‘ Self ‘ ‘ ‘
7. Im paired judgm ent ‘ ‘ ‘ 12. Other Cognitive / Mental
Status Inform ation:

Patient Ability to Take/Administer Medication:

Never Som etim es* Always *Com plete #7.

1. Totally independent ‘ ‘ ‘ 6. Patient/care giver can be

2. Needs rem inding ‘ ‘ ‘ taught to adm inister ‘ Yes ‘ No
3. Non-com pliant ‘ ‘ ‘ 7. Please explain:
4. Needs help preparing ‘ ‘ ‘
5. Needs adm inistration ‘ ‘ ‘

If patient is not independent, what arrangem ents have been m ade to adm inister m edications?

IV Infusion and Injections: # of Times Per W eek

Patient requires hom e infusion via: ______________
‘ Central Line ‘ Peripheral Line
Injections ______________

Blood work (in the hom e) ______________

Elimination:
Bowel Bladder

Continent ‘ ‘
Occasionally Incontinent ‘ ‘
Incontinent ‘ ‘

Medical Treatment: (Check T all that apply) Please list all medications on AI485:

1. Decubitus care ‘ 6. Monitor vital signs ‘ 11. Blood tests ‘

2. Dressings - Sim ple ‘ 7. Tube feeding ‘ 12. Am bulation exercise ‘
3. Dressings - Sterile ‘ 8. Tube irrigation ‘ 13. Rehabilitative therapy ‘
4. Enem a ‘ 9. Suctioning ‘ 14. Physical therapy ‘
5. Catheter care ‘ 10. Oxygen adm inistration ‘
New York State Department of Health
Uninsured Care Programs Nursing Assessment - Page 3 of 3

Patient Name:_____________________________________________________ ADAP ID#: 555-_________________

Agency: __________________________________________________________ Provider Num ber_______________

Identification of Service Needs:

W ithout W ith W ith W ith W ith
Help Cane W alker W heelchair Personal Unable
Assistance

Am bulate inside ‘ ‘ ‘ ‘ ‘ ‘
Am bulate outside ‘ ‘ ‘ ‘ ‘ ‘
Get up from seated position ‘ ‘ ‘ ‘ ‘ ‘
Get up from bed ‘ ‘ ‘ ‘ ‘ ‘
Transfer to:
Com m ode ‘ ‘ ‘ ‘ ‘ ‘
W heelchair ‘ ‘ ‘ ‘ ‘ ‘

Indicate Patient’s Personal Service Needs:

Partial Total Partial Total
Independent Assist Assist Independent Assist Assist

Groom ing ‘ ‘ ‘ Toileting/ Bathroom ‘ ‘ ‘

Dressing ‘ ‘ ‘ Urinal or bedpan ‘ ‘ ‘
W ashing ‘ ‘ ‘ Com m ode ‘ ‘ ‘
Bathing ‘ ‘ ‘ Catheter ‘ ‘ ‘
Feeding ‘ ‘ ‘ Laundry ‘ ‘ ‘
Meal Prep ‘ ‘ ‘ Shopping ‘ ‘ ‘
Reheat Meals ‘ ‘ ‘ Housecleaning ‘ ‘ ‘

Is the patient homebound? ‘ Yes ‘ No*

*If patient is not hom ebound, you m ust subm it justification of hom e care separately.

Certification:
This assessm ent is based on personal observation of the patient. ‘ Yes ‘ No
This assessm ent is based on inform ation relayed to m e by: ______________________________________________

Prepared by: (print nam e)___________________________________________ Phone #:_____________________

Agency Affiliation:_________________________________________________ FAX#: _______________________
Signature:________________________________________________________ Date: ________________________

Is any other agency/vendor providing services in the hom e to the patient? ‘ Yes ‘ No
If Yes, Agency Nam e:___________________________________Services:__________________________________
Have all hom e care insurance benefits been exhausted? ‘ Yes ‘ No
Is this patient eligible for Medicaid? ‘ Yes ‘ No Have they applied to Medicaid? ‘ Yes ‘ No
If No, state reasons:_____________________________________________________________________________

FOR NEW HOM E CARE APPLICANT ONLY:

How was the applicant referred to your agency?

‘ Doctor ‘ Social W orker ‘ Discharge Planner Location:___________________________________________
‘ Other Please explain:___________________________________________________________________________

(Rev. 12/2005)