CASE MANAGER Patient Label

INITIAL ASSESSMENT FORM

Date: ………………………………………………………… Time: …………………………………………………………………..

Medical Diagnosis: ………………………………………………………………………………………………………………….
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Patient Screening:
 Patient with complex cases (≥ 3 doctors involved)
 There is a risk of continuing care at home with moderate or high dependency
 Day of admission ≥ 7 days
 Patient with likelihood of financial complexity
 Patient with procedure that need extensive payment
 Patient with high risk of complain
 Patient with chronic disease that have low obedience to treatment program
 Patient using clinical pathway
 Re-admission patient
 Terminal patient

Case Manager Assessment:

Past Medical History:
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History of Medical Treatment and Alternative Treatment:
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History of Trauma and Violence:
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Cognitive and mental state in need of accepting change:
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Level of independent:
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Family support and family ability to perform nursing care:
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Patient perception of healthy concept and illness:
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Expectation of nursing outcomes:
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Nursing care plan:
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. Financial support or insurance support:
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. Risk - problem identification and prognosis:
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. Case manager plan:
Date / Risk - problem Target and
Time identification and Case Manager Plan Time
prognosis Frame

Badung,……………………………………………

(……………………………………………………)
Case Manager

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CASE MANAGER
Patient
IMPLEMENTATION RECORD Label

Date&Time Case Manager Notes Case manager

Print name & Sign

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