Home Care Services

Initial Assessment

Date of service (date of assessment) (yyyy-mm-dd)

     
Worker’s information
Worker’s last name First name Middle initial WorkSafeBC claim number
                       
Home address (where service is to be provided)
     
City Province Postal code Phone number (include area code) Date of birth (yyyy-mm-dd)

                             

Name of worker’s next of kin Phone number (include area code)

           
Name of family doctor Phone number (include area code)

           
Name(s) of other health professionals involved Phone number (include area code)

           
Reason for assessment
     

WorkSafeBC’s information
WorkSafeBC Board Officer’s name (please print) Phone number (include area code)

           
Was the Board Officer contacted to discuss the findings of this assessment?
Yes No
If yes, name of person contacted If no, explain why not
           

Agency’s information
Agency’s/company’s name Payee number
           
Mailing address
     
City Province Postal code Phone number (include area code) Fax number (include area code)

                             

Current supports
Home environment Describe (e.g. building type, layout, size, # of floors; concerns such as access, clutter)
Lives Alone With partner/spouse With family      
Description of current informal support (who is involved and how they assist, e.g. family/friend(s), church)

     
Description of current services/formal support not being delivered by the agency
(e.g. delivered meals, community nursing, community transport, medical alarm monitoring, education, rehabilitation)

     
Is there evidence of any barriers to service that WorkSafeBC If yes, provide details
should know about?
     
Yes No

83M378 (18/05) Page 1 of 4

 Home Care Services
Initial Assessment

Worker’s last name First name Middle initial WorkSafeBC claim number

Health status
Summary of claim-related injury
     
Pertinent, non-claim related health history
     
Functional Status and limitations (including pain scale, etc.)

     
Bowel/bladder care (provide details)

     
Current medications (list all, include name, dosage, and frequency) N/A
     
Allergies (food and/or other) N/A
     
Nutrition/weight (describe current level of nutrition/appetite; comment on any changes/concerns)

     

Integumentary
Skin integrity/wounds/foot care (describe in detail, e.g. wound history, size, stage, odour, drainage) N/A
     

Behaviour/cognition/psychosocial
Behaviour
No issues at present Agitated Verbally abusive Comments (provide details)

Anxious Cooperative behavior Withdrawn      

Cognition

Mentally alert Confused at times Comments (provide details)

     
Oriented to:
Person Place Time

Able to:

Make decisions Communicate Comprehend

Problem solve Initiate Remember
Concentrate appointments

Psychosocial
No issues at present No social relationships Comments (provide details)
Staff interaction only
Involved in social      
activities
Goes out:

Regularly Occasionally Rarely

83M378 (18/05) Page 2 of 4

 Home Care Services
Initial Assessment

Worker’s last name First name Middle initial WorkSafeBC claim number

Current equipment/adaptive aids

General
Manual wheelchair Straight-legged walker Scooter Brace
Power wheelchair Two-wheeled walker Stair lift Splints
Bariatric wheelchair Four-wheeled walker Cane Prosthesis
Other           With seat? Crutches

Comments
     

Bedroom
Bed
Normal Hospital Adjustable Bariatric
Mattress (describe, including toppers/cushions)

     
Lift (ceiling/portable) Bed rail Transfer bench
Comments
     

Bathroom
Grab bars Safety grips/bath mats Commode Hand-held shower
Tub bar Bath board Raised toilet seat Lift (ceiling/portable)

Other           Bath chair Bath bench

Comments
     

Other equipment (describe, e.g. kitchen equipment, etc.)

     

Safety
Identify and comment on any safety risks that are/may be present
     

Recommendations/plan

Estimated length of service 0 to 6 weeks 6 weeks to 6 months More than 6 months

Description of services to be provided by agency (please give specific detail, such as what tasks are to be performed)

     

Services to be provided
Note: Nursing services for reporting purposes do not need to be included
Service Number of hours/day Number of Days/week

83M378 (18/05) Page 3 of 4

 Home Care Services
Initial Assessment

Worker’s last name First name Middle initial WorkSafeBC claim number

Registered nurse (RN)       or range       to             or range       to      
Licensed practical nurse (LPN)       or range       to             or range       to      

Health Care Assistant (HCA) Monday       or range       to             or range       to      
Tuesday       or range       to      
Wednesday       or range       to      
Thursday       or range       to      
Friday       or range       to      
Saturday       or range       to      
Sunday       or range       to      
Comments (as needed for clarification of the RN/LPN/HCA hours stated above)

     
Service goals (describe specific goal(s) and expected outcome(s))

     
Service start date (yyyy-mm-dd) Anticipated discharge date (if known) (yyyy-mm-dd)

           
Date the Board Officer authorized the level of services above (yyyy-mm-dd) Board Officer name
           

Additional information
Comments
     
I hereby certify that the information contained herein is complete and accurate to the best of my knowledge.

Assessment completed by (first & last name) Title (RN/LPN) Contact phone number (include area code) Signature
                 
Next scheduled RN/LPN visit (yyyy-mm-dd)

     

Claims Call Centre Fax Mail

Phone 604.231.8888 604.233.9777 WorkSafeBC
Toll-free 1.888.967.5377 Toll-free 1.888.922.8807 PO Box 4700 Stn Terminal
M–F, 8 a.m. to 6 p.m. Vancouver BC V6B 1J1
WorkSafeBC collects information on this form for the purposes of administering and enforcing the Workers Compensation Act. That Act, along with the
Freedom of Information and Protection of Privacy Act, constitutes the authority to collect such information. To learn more about the collection of personal
information, contact WorkSafeBC’s freedom of information coordinator at PO Box 2310 Stn Terminal, Vancouver BC, V6B 3W5, or call 604.279.8171.

83M378 (18/05) Page 4 of 4