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Name:

Age:
Classification of OA: (Young OA, Middle OA, Old OA)

ASSESSMENT FINDINGS (ABNORMAL ONLY)


Respiratory
Cardiovascular
Gastrointestinal
Urinary
Reproductive
Musculoskeletal
Sensory (Vision, Smell, taste,
tactile sensation, auditory)
Endocrine
Integumentary
Immune system
Changes to mind

Functional Assessment:

Psychospiritual Assessment:

Psychological Assessment

Cognitive:

Affective:

Sociospiritual Assessment

Support Systems

Financial Resources

Occupational and Educational History

Living Arrangement

Interest and routines

Nutrition

Alcohol, drug, and tobacco use

Sleep Hygiene

Sexuality

Cultural and Ethnic Background


Abuse and Neglect

End-of-Life decisions

Spirituality

Mental Health

SUMMARY
(about the assessment and how do you feel about making the plan of care in
narrative)

1 Priority NCP

Documentation

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