ࡱ> oqhijklmn#` nbjbj\.\. _>D>D5Q@@@$dȘȘȘPdj3+4  0000000$4h^730@ZZZ30$3LLLZ@ 0LZ 0LL 6@ MdAȘ*9:30j3, 8 8 8@(y'|LdSyyy3030^yyyj3ZZZZddddȘdddȘddd  Optional Long Term Care Assessment and Care Planning Tool LONG TERM CARE OPTIONAL ASSESSMENT & CARE PLANNING TOOL    Background Information Date: FORMTEXT       Individual s Name:  FORMTEXT      Nick Name:  FORMTEXT      Age:  FORMTEXT      Birthplace:  FORMTEXT      Gender:  FORMCHECKBOX  M  FORMCHECKBOX  FPrimary Language:  FORMTEXT      Ethnic Background:  FORMTEXT      Assessment Location (address):  FORMTEXT      Previous Living Situation:  FORMTEXT      Marital Status FORMCHECKBOX  Married  FORMCHECKBOX  Divorced  FORMCHECKBOX  Widow(er) Maiden Name:  FORMTEXT      Spouse s Name:  FORMTEXT      Children s Name(s): FORMTEXT      Primary Contact Person:  FORMTEXT      Phone:  FORMTEXT        FORMTEXT      - FORMTEXT      Social Security #  FORMTEXT      - FORMTEXT      - FORMTEXT       Medicare#  FORMTEXT      - FORMTEXT      - FORMTEXT      Medicaid #  FORMTEXT      - FORMTEXT      - FORMTEXT       Hospice Client:  FORMCHECKBOX  Yes  FORMCHECKBOX  NoVeteran  FORMCHECKBOX  Yes  FORMCHECKBOX  NoBranch of Services:  FORMTEXT      Health Insurance Company:  FORMTEXT       Phone:  FORMTEXT        FORMTEXT      - FORMTEXT      Policy #:  FORMTEXT      Pre-authorization required:  FORMTEXT       Yes  FORMTEXT       NoOther Insurance Coverage:  FORMTEXT      Policy #:  FORMTEXT      SUBSTITUDE DECISION-MAKER  FORMCHECKBOX  Yes  FORMCHECKBOX  No (supply copy to adult family home)  FORMTEXT      Name:  FORMTEXT      Phone:  FORMTEXT        FORMTEXT      - FORMTEXT      Indicate type (Guardian, POA, DPOA, Representative Payee, family member): FORMTEXT      Name:  FORMTEXT       Address:  FORMTEXT       Phone:  FORMTEXT      Name:  FORMTEXT       Address:  FORMTEXT       Phone:  FORMTEXT      PRIMARY PHYSICIAN:  FORMTEXT      Clinic Address:  FORMTEXT      Phone:  FORMTEXT        FORMTEXT      - FORMTEXT      Fax:  FORMTEXT        FORMTEXT      - FORMTEXT      SPECIALIST:  FORMTEXT      Phone:  FORMTEXT        FORMTEXT      - FORMTEXT      Fax:  FORMTEXT        FORMTEXT      - FORMTEXT      SPECIALIST:  FORMTEXT      Phone:  FORMTEXT        FORMTEXT      - FORMTEXT      Fax:  FORMTEXT        FORMTEXT      - FORMTEXT      DENTIST:  FORMTEXT      Phone:  FORMTEXT        FORMTEXT      - FORMTEXT      Fax:  FORMTEXT        FORMTEXT      - FORMTEXT      PHARMACY: FORMTEXT      Phone:  FORMTEXT        FORMTEXT      - FORMTEXT      Fax:  FORMTEXT        FORMTEXT      - FORMTEXT      Preferred Hospital:  FORMTEXT       Address:  FORMTEXT      Phone:  FORMTEXT        FORMTEXT      - FORMTEXT      ADVANCE DIRECTIVES:  FORMCHECKBOX  Yes  FORMCHECKBOX  No (supply copy to adult family home, where is original kept?)  FORMTEXT      Funeral Arrangements Made:  FORMCHECKBOX  Yes  FORMCHECKBOX  NoWith Whom:  FORMTEXT      Phone:  FORMTEXT        FORMTEXT      - FORMTEXT      Current Height:  FORMTEXT      Current Weight:  FORMTEXT      KNOWN ALLERGIES/REACTIONS:  FORMTEXT      CURRENT MEDICAL DIAGNOSIS: (only include diagnoses made by licensed medical professional):  FORMTEXT      Date of most recent exam:  FORMTEXT      By whom:  FORMTEXT       Also include if appropriate:  FORMTEXT       " history of mental illness " diagnosis of a developmental disability " recent surgeries and hospitalizationDate:  FORMTEXT      Diagnosis:  FORMTEXT       By Whom:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Current Prescribed Medications Medication Include prescribed, over the counter & herbal.What is medication being used for.Dosage, route and frequency.Special Instructions Notes Regarding Contraindications Common Side Effects FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Date: FORMTEXT      This list is only current at the time of assessment. You may contact the Pharmacist or Physician to inquire about contraindications. Please assess level of assistance required to take medications in the Activities of Daily Living section. Preferences and Choice in Daily Life Document Source of Information Date and Initial Entries Preliminary and Negotiated Care Plan: What are the individuals strengths, needs and preference? When will assistance be provided? Who will provide assistance?Current or Prior Occupation: FORMTEXT      Education: FORMTEXT      Lifetime Hobbies: FORMTEXT      Involvement Patterns: Prefer to be alone?  FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT      At ease with others:  FORMCHECKBOX  Yes  FORMCHECKBOX  NoSelf-initiates activities?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoEnjoys group activities?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoEnjoys new activities?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoLimitations that impact involvement?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoFamily/Friends Relationship: Close relationships?  FORMCHECKBOX  Yes  FORMCHECKBOX  No (with whom?) FORMTEXT      Someone to confide in?  FORMCHECKBOX  Yes  FORMCHECKBOX  No (Whom?)  FORMTEXT       FORMCHECKBOX  Recent loss of family/friend? Whom?  FORMTEXT       FORMCHECKBOX  Strategies/items to increase comfort?Social/Cultural Preferences  FORMCHECKBOX  Cultural considerations or preferences:  FORMTEXT       FORMTEXT       FORMCHECKBOX  Enjoys children  FORMCHECKBOX  Enjoys petsHas a pet they want to keep  FORMTEXT       Yes  FORMTEXT      NoUsual Patterns FORMTEXT       FORMCHECKBOX  Stays up late  FORMCHECKBOX  Arises early  FORMCHECKBOX  Sleeps in FORMCHECKBOX  Naps  FORMCHECKBOX  Irregular sleep habits  FORMCHECKBOX  Awakes at nightFinds strength in faith  FORMCHECKBOX  Attends church activities Where?  FORMTEXT       FORMTEXT      Preferred Household Activities Enjoys helping with:  FORMCHECKBOX  Laundry  FORMCHECKBOX  Housecleaning  FORMCHECKBOX  Dishes  FORMCHECKBOX  Cooking  FORMCHECKBOX  Other: FORMTEXT      Preferred Activity Time  FORMCHECKBOX  Morning  FORMCHECKBOX  Afternoon  FORMCHECKBOX  Evening  FORMCHECKBOX  Night FORMTEXT      Activity Preferences  FORMCHECKBOX  Music  FORMCHECKBOX  Cards/Games  FORMCHECKBOX  Trips/Shopping  FORMCHECKBOX  Gardening/Plants  FORMCHECKBOX  Time Outdoors  FORMCHECKBOX  Talking/Conversing  FORMCHECKBOX  Helping Others  FORMCHECKBOX  Computers  FORMCHECKBOX  Reading/Writing  FORMCHECKBOX  Exercise/Sports  FORMCHECKBOX  TV  FORMCHECKBOX  Crafts/Arts  FORMCHECKBOX  Other Activity Interests: FORMTEXT       Delirium, Depression and Cognition Screening It is helpful to screen for delirium and depression before looking at cognitive abilities Delirium Screening Delirium can be due to a general medical condition, such as (but not limited to) the following: a fall, an infection or an electrolyte imbalance; or due to a substance induced situation, such as a medication change or an abuse or misuse of a medication or another toxic substance. One or both of the following could be indicators of delirium if this represents a change to the individuals regular functioning:  Sudden or new onset/change in mental functioning, this includes changes in one s ability to pay attention, awareness of surrounding, being coherent, or an unpredictable variation over the course of the day.  Episode of disorganized speech (e.g. speech is incoherent, nonsensical, irrelevant, or rambling from subject to subject; loses train of thought). (If a box is checked, consider immediate referral to medical health professional.)Depression Screening The following is a list of possible indicators of depression. It is important that individuals who are experiencing several of these signs for a period of two weeks or more seek advice from a health care professional that is licensed to treat depression. Depressed mood, irritable mood, or loss of interest or pleasure in nearly all activities.  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Unable to assess Change in appetite  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Unable to assess Weight gain or loss (>5% of body weight)  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Unable to assess Insomnia or hyper-somnia (sleeping all the time)  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Unable to assess Psychomotor agitation (inability to sit still/pacing/hand wringing/pulling or rubbing of the skin, clothing, or other objects) or retardation (slowed speech/thinking and body movements)  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX Unable to assess Decreased energy and fatigue without physical exertion  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Unable to assess Feelings of worthlessness or guilt  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Unable to assess Difficulty thinking, concentrating, or making decisions (pseudo dementia)  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Unable to assess Recurrent thoughts of death, suicide ideation, do they have a plan or has there been an attempt:  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Unable to assessRelevant History of Depression and need for Follow-up History Need for Follow-up  FORMCHECKBOX  Hospitalization  FORMTEXT        FORMCHECKBOX  Prior Medication  FORMTEXT        FORMCHECKBOX  Prior Treatments  FORMTEXT       What has worked? What has not worked?  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       History of Anxiety Excessive worry, apprehension, fears, nervousness or agitation are often indicators of anxiety. History Need for Follow-up  FORMCHECKBOX  Hospitalization  FORMTEXT        FORMCHECKBOX  Prior Medication  FORMTEXT        FORMCHECKBOX  Prior Treatments  FORMTEXT       What has worked?  FORMTEXT       What has not worked?  FORMTEXT        FORMTEXT        FORMTEXT        Cognitive Screening  FORMCHECKBOX  Individual is comatose  FORMCHECKBOX  Yes  FORMCHECKBOX  No (If yes do not continue)MemoryShort-Term Memory Method # 1: Ask the individual to describe a recent event that you both had the opportunity to remember. This might be breakfast, a recent meal, or the weather the day before. Ask for details.Method #2: Ask the individual if you may test their memory. Then say the names of three unrelated objects (i.e. table, comb, tree) clearly and slowly, about on second for each. Ask to repeat them to verify that you were heard and understood, and ask them to remember the objects. Proceed to talk about something else for five minutes and then ask them to recall the objects. Of the individual is unable to recall all three items, there is evidence of memory problems. FORMCHECKBOX  Short-term memory okay FORMTEXT       Short-term memory problemLong-term Memory and OrientationAsk the individual several of the following questions:What your name? What day is it today?Where do you live?What is the address?Are you married?What is your spouse s name?Do you have any children?What are their names?When is your birthday?What year were you born?Verify answers for accuracy. FORMCHECKBOX  Long-term memory okay FORMCHECKBOX  Long-term memory problemsOriented to person?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Oriented to place?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Oriented to time?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoCognitive Skills for Daily Decision Making/JudgmentDetermine how the individual makes decisions about everyday tasks or activities of daily living. It is also important to consult with caregivers, family and other persons who know this individual in order to understand how this individual is presently functioning.How does the individual make decisions about organizing the day, e.g., when to get up or have meals: which clothes to wear or activities to be involved in? Is the individual aware of their need for assistive devices and use them appropriately? How would this individual respond in an emergency, are they aware of personal strengths and weaknesses? Is individual currently making his or her own decisions about daily living?  FORMTEXT       FORMCHECKBOX  Decisions are consistent, reasonable, and organized  reflecting lifestyle, culture, values. (Independent) FORMCHECKBOX  Organized daily routine, safe decisions in familiar situations, experiences some difficulty in new situations. (Modified Independence)  FORMTEXT       FORMCHECKBOX  Decisions are poor; requires reminders, cues, and supervision in planning organizing daily routines. (Moderately Impaired)  FORMTEXT       FORMCHECKBOX Decision-making severely impaired; never/rarely makes decisions. (Severely Impaired)  FORMTEXT       Recent Medical History/Significant Symptoms Assessment Recent Medical History Significant SymptomsDocument Source of Information Date and Initial Entries Preliminary and Negotiated Care Plan: What are the individuals strengths, needs and preference? When will care be provided? Who will provide care?Vision Date of last exam:  FORMCHECKBOX  Impaired-sees large print  FORMCHECKBOX  Limited vision, can see shapes, headlines and identify objects  FORMCHECKBOX  Significant impaired vision, difficulty identifying objects  FORMCHECKBOX  Severely impaired, sees only light/colors, can not track objects  FORMCHECKBOX  Blind  FORMCHECKBOX  Left  FORMCHECKBOX  Right Cataracts  FORMCHECKBOX  Left  FORMCHECKBOX  Right Surgery  FORMCHECKBOX  Left  FORMCHECKBOX  Right  FORMCHECKBOX  Glasses  FORMCHECKBOX  Contact lenses  FORMCHECKBOX  Other: FORMCHECKBOX  No problem identifiedHearing Date of last exam:  FORMCHECKBOX  Difficulty when not in quiet setting  FORMCHECKBOX  Hears only in special situations, must adjust tonal quality and volume  FORMCHECKBOX  Highly impaired-no useful hearing Loss  FORMCHECKBOX  Left  FORMCHECKBOX  Right Aids  FORMCHECKBOX  Left  FORMCHECKBOX  Right Other:  FORMTEXT       FORMCHECKBOX  No problem identifiedCommunication Making Self Understood  FORMCHECKBOX  Usually able-difficulty finding words or finishing thoughts  FORMCHECKBOX  Sometimes able-makes simple requests regarding needs and preferences  FORMCHECKBOX  Rarely/never able-someone else must interpret sounds or body language  FORMCHECKBOX  Problems with speech charity  FORMCHECKBOX  Uses sign language, reads lips, communication device  FORMCHECKBOX  Other FORMCHECKBOX  No problem IdentifiedAbility to Understand Others  FORMCHECKBOX  Usually able-demonstrates understanding in words or actions-may miss some part or intent  FORMCHECKBOX  Sometimes able-frequent difficulty-responds to simple and direct questions and directions  FORMCHECKBOX  Rarely or never able-very limited ability-or caregivers cannot determine.  FORMCHECKBOX  Other: FORMCHECKBOX  No problem Identified Recent Medical History/Significant Symptoms Assessment Recent Medical History Significant SymptomsDocument Source of Information Date and Initial Entries Preliminary and Negotiated Care Plan: What are the individuals strengths, needs and preference? When will care be provided? Who will provide care?Oral Problems Date of last exam: FORMTEXT        FORMCHECKBOX  Own teeth Dentures  FORMCHECKBOX  Upper  FORMCHECKBOX  Lower Partials  FORMCHECKBOX  Upper  FORMCHECKBOX  Lower  FORMCHECKBOX  Missing teeth, does not use dentures or partials  FORMCHECKBOX  Broken/loose teeth  FORMCHECKBOX  Inflamed/bleeding gums  FORMCHECKBOX  Dry mouth  FORMCHECKBOX  Other:  FORMTEXT       FORMCHECKBOX  No problem identifiedLung/Breathing Problems  FORMCHECKBOX  Difficulty breathing/shortness of breath  FORMCHECKBOX  During activity  FORMCHECKBOX  Resting  FORMCHECKBOX  Wheezing  FORMCHECKBOX  Coughing  FORMCHECKBOX  Sinus problems  FORMCHECKBOX  Other:  FORMTEXT       FORMCHECKBOX  No problem identifiedCardiovascular Problems  FORMCHECKBOX  Chest pain  FORMCHECKBOX  Irregular  FORMCHECKBOX  High  FORMCHECKBOX  Low blood pressure  FORMCHECKBOX  Dizziness  FORMCHECKBOX  Edema where:  FORMCHECKBOX  Cold feet  FORMCHECKBOX  Varicose veins  FORMCHECKBOX  Other: FORMTEXT       FORMCHECKBOX  No problem IdentifiedGastrointestinal  FORMCHECKBOX  Heartburn  FORMCHECKBOX  Regurgitates food  FORMCHECKBOX  Abdominal pain  FORMCHECKBOX  Hemorrhoids  FORMCHECKBOX  Black/bloody stools  FORMCHECKBOX  Other: FORMTEXT       FORMCHECKBOX  No problem IdentifiedKidney/Urinary Tract Problems  FORMCHECKBOX  Chronic Infections  FORMCHECKBOX  Stones  FORMCHECKBOX  Other:  FORMTEXT       FORMCHECKBOX  No problem Identified Recent Medical History/Significant Symptoms Assessment Recent Medical History Significant SymptomsDocument Source of Information Date and Initial Entries Preliminary and Negotiated Care Plan: What are the individuals strengths, needs and preference? When will care be provided? Who will provide care?Bowel and Bladder Bladder  FORMCHECKBOX  Usually continent-incontinent no more than 1/wk  FORMCHECKBOX  Occasionally incontinent-2/wk or more, urgency  FORMCHECKBOX  Frequently incontinent-daily  FORMCHECKBOX  Totally incontinent Bowel  FORMCHECKBOX  Occasionally incontinent 1/wk  FORMCHECKBOX  Frequently incontinent 2-3/wk  FORMCHECKBOX  Totally incontinent FORMCHECKBOX  No problem identifiedMuscular-skeletal  FORMCHECKBOX  Limited range of motion  FORMCHECKBOX  Contractors  FORMCHECKBOX  Foot Problems  FORMCHECKBOX  Bone/Joint Pain  FORMCHECKBOX Missing limbs  FORMCHECKBOX  Ortho devices (prosthetic)  FORMCHECKBOX  Other:  FORMTEXT       FORMCHECKBOX  No problem identifiedNervous System  FORMCHECKBOX  Tremors  FORMCHECKBOX  Seizures  FORMCHECKBOX  Viral Infection  FORMCHECKBOX Hepatitis  FORMCHECKBOX  Other: FORMTEXT       FORMCHECKBOX  No problem IdentifiedImmunizations (dates if known)  FORMCHECKBOX  Tuberculosis test  FORMCHECKBOX  Flu  FORMCHECKBOX  Tetanus  FORMCHECKBOX  Hepatitis  FORMCHECKBOX  Pneumonias  FORMCHECKBOX  Other: FORMTEXT       FORMCHECKBOX  No problem IdentifiedPain Management  FORMCHECKBOX  Has pain/severity: 1-10 Describe: Location/Duration/Cause  FORMTEXT       FORMCHECKBOX  No problem IdentifiedSubstance Use Drinks alcohol  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  History of problems/treatment  FORMCHECKBOX  Tobacco use  FORMCHECKBOX  Current or past drug addiction FORMCHECKBOX No problem Identified Activities of Daily Living Assessment Include specialized body care Consider functioning in last seven daysDocument Source of Information Date and Initial Entries Preliminary and Negotiated Care Plan: What are the individuals strengths, needs and preference? When will care be provided? Who will provide care?Positioning Ability to move about in bed or a chair, turn side to side, and position body for comfort in bed or chair.  FORMCHECKBOX  Standby for safety, cueing monitoring, or encouragement  FORMCHECKBOX  Able to turn or reposition but requires help to guide limbs in order to turn or reposition  FORMCHECKBOX  Able to assist, requires one person to support while moving or lifting part of body  FORMCHECKBOX  Dependent on one person to turn or reposition  FORMCHECKBOX  Dependent on more than one person to turn or position  FORMCHECKBOX Reposition every  FORMTEXT       hours,  FORMCHECKBOX  day time  FORMCHECKBOX  night time Special Equipment  FORMCHECKBOX  Draw sheet  FORMCHECKBOX  Hospital bed  FORMCHECKBOX  Special mattress  FORMCHECKBOX  Trapeze  FORMCHECKBOX  Wedge  FORMCHECKBOX  Foot Cradle  FORMCHECKBOX  Bed rails  FORMCHECKBOX  Other: FORMTEXT       FORMCHECKBOX  Moves independently without assistanceTransfers Ability to move to/from bed, chair, wheelchair, stand to sit, sit to stand.  FORMCHECKBOX  Able to transfer, requires standby for safety, encouragement or cueing  FORMCHECKBOX  Able to support own weight, requires hands-on guiding  FORMCHECKBOX  Able to support some of own weight, requires lifting assistance to stand or sit  FORMCHECKBOX  Unable to assist, requires full lifting by one person  FORMCHECKBOX  Unable to assist, requires full lifting by two or more  FORMCHECKBOX  Requires mechanical lifting  FORMCHECKBOX  Other:  FORMTEXT       FORMCHECKBOX  Transfers independently and safely without assistance Activities of Daily Living Assessment Include specialized body care Consider functioning in last seven daysDocument Source of Information Date and Initial Entries Preliminary and Negotiated Care Plan: What are the individuals strengths, needs and preference? When will care be provided? Who will provide care?Personal Hygiene Ability to shave; do make-up; wash hands, face and perineum; care for hair, teeth, dentures, hearing aids, glasses  FORMCHECKBOX  Requires set-up What?  FORMTEXT        FORMCHECKBOX  Requires monitoring, encouragement and/or cueing  FORMCHECKBOX  Able to perform, but requires hands-on assistance to guide through task completion  FORMCHECKBOX  Able to assist, but dependent in at least one sub task  FORMCHECKBOX  Unable to assist, dependent  FORMCHECKBOX  Care of prosthetic devices Skin Problems  FORMCHECKBOX  Dry Skin  FORMCHECKBOX  Fragile/tears  FORMCHECKBOX  Moles/growths  FORMCHECKBOX  Bruises easily  FORMCHECKBOX  Rashes/Itchy skin  FORMCHECKBOX  Skin allergies  FORMCHECKBOX  Other  FORMTEXT        FORMCHECKBOX  Lotions/soaps/linens  FORMCHECKBOX  Nail care  FORMCHECKBOX  Menstruating Normal cycle?  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12@ABJKUVzjj<h^M5CJU\jz<h^M5CJU\j<h^M5CJU\j;h^M5CJU\j;h^M5CJU\j:h^M5CJU\j":h^M5CJU\jh^M5CJU\j9h^M5CJU\h^M5CJ\& ,.0^`|~*,@BDNPRTprtNO]׷קחׇwq h^MCJj?h^M5CJU\jJ?h^M5CJU\j>h^M5CJU\jZ>h^M5CJU\j=h^M5CJU\jj=h^M5CJU\h^M5CJ\jh^M5CJU\$jh^M5CJU\mHnHu&^RҟNtLLdM(NNqkd:@$$Ifl0%L t0d&64 la $$Ifa$]^_ȠɠʠLtLvLLLLLLMMM2M4MPMRMTMdMfMMMMMٹ٩٧ٗهwgjDh^M5CJU\jCh^M5CJU\j-Ch^M5CJU\jBh^M5CJU\Uj=Bh^M5CJU\jAh^M5CJU\jMAh^M5CJU\h^M5CJ\jh^M5CJU\j@h^M5CJU\(mbs and/or help with tying or buttoning  upper  lower  FORMCHECKBOX  Able to assist, but requires supporting of limbs  FORMCHECKBOX  upper  FORMCHECKBOX  lower  FORMCHECKBOX  Unable to assist, dependent  FORMCHECKBOX  1  FORMCHECKBOX  2 person  FORMCHECKBOX  Other: FORMTEXT       FORMCHECKBOX  Dresses independently and appropriately Activities of Daily Living Assessment Include specialized body care Consider functioning in last seven daysDocument Source of Information Date and Initial Entries Preliminary and Negotiated Care Plan: What are the individual s strengths, needs and preference? When will care be provided? Who will provide care?Ambulation/Mobility Ability to walk, move between locations with or without assistive devices  FORMCHECKBOX  Independent in walking, uses assistive devices  FORMCHECKBOX  Does not walk, mobile with wheel chair  FORMCHECKBOX  Independently in walking with or without assistive devices, needs stand-by assistance for safety and cueing  FORMCHECKBOX  Supports own weight when walking, with or without assistive devices, needs steadying  FORMCHECKBOX  Walks with weight bearing support from 1 person  FORMCHECKBOX  Walks with weight bearing support from 2 persons  FORMCHECKBOX  Does not walk or use wheel chair  FORMCHECKBOX  Bed bound FORMCHECKBOX  Independent, no assistance or assistive devicesAmbulation  FORMCHECKBOX  Limited to  FORMTEXT       feet Limitation due to:  FORMTEXT       General stamina:  FORMTEXT        FORMCHECKBOX  Prone to falls FORMCHECKBOX  Independent-ambulates unlimited distanceAbility to Negotiate Stairs  FORMCHECKBOX  Able to go up or down stairs, requires assistive devices or stand-by assistance  FORMCHECKBOX  Not able to go up/down stairs  FORMCHECKBOX  Unable to assess FORMCHECKBOX  Independently goes up and down stairsEquipment Used  FORMCHECKBOX  Cane  FORMCHECKBOX  Crutches  FORMCHECKBOX  Walker  FORMCHECKBOX  Quad Cane  FORMCHECKBOX  Gait Belt  FORMCHECKBOX  Requires prosthesis  FORMCHECKBOX  Wheelchair  FORMCHECKBOX  Regular  FORMCHECKBOX  Electric  FORMCHECKBOX  Self-propels  FORMCHECKBOX  Needs Assistance  FORMCHECKBOX  Other  FORMTEXT       FORMCHECKBOX  No equipment used Activities of Daily Living Assessment Include specialized body care Consider functioning in last seven daysDocument Source of Information Date and Initial Entries Preliminary and Negotiated Care Plan: What are the individual s strengths, needs and preference? When will care be provided? Who will provide care?Toilet Use Ability to use the commode, bedpan, urinal; transfer on/off toilet, manage clothing, cleanse, change pads, manage ostomy/catheter  FORMCHECKBOX  Set-up supplies only  FORMCHECKBOX  Requires monitoring, encouragement and/or cueing  FORMCHECKBOX  Able to assist, but requires assistance with cleansing/care/pads/clothing and/or stand-by assistance for transfer  FORMCHECKBOX  Able to assist, dependent in at least one task and/or requires lifting assistance to transfer  FORMCHECKBOX  1 person  FORMCHECKBOX  2 person  FORMCHECKBOX  Unable to assist, dependent for all toileting tasks  FORMCHECKBOX  1 person  FORMCHECKBOX  2 person Needs assistance at night How often?  FORMTEXT        FORMCHECKBOX  Urinates  FORMCHECKBOX  Defecates in inappropriate places Where ?  FORMTEXT       FORMCHECKBOX  Independent with toileting tasksBowel  FORMCHECKBOX  Training Program  FORMCHECKBOX  Bowel Aids  FORMCHECKBOX  Impaction  FORMCHECKBOX  Enemas  FORMCHECKBOX  Constipation  FORMCHECKBOX  Diarrhea FORMTEXT      Bladder  FORMCHECKBOX  Bladder Training/Program  FORMCHECKBOX  Dribbling  FORMCHECKBOX  Urgency  FORMCHECKBOX  Stress incontinence when exercising, sneezing, coughing  FORMCHECKBOX  Difficulty starting urine flow Uses:  FORMCHECKBOX  Pads  FORMCHECKBOX  Undergarments  FORMCHECKBOX  Nights  FORMCHECKBOX  Days  FORMCHECKBOX  Full-time  FORMCHECKBOX  Catheter  FORMCHECKBOX  Bed  FORMCHECKBOX  Leg Size  FORMTEXT        FORMCHECKBOX  Indwelling  FORMCHECKBOX  Intermittent  FORMCHECKBOX  Ostomy type:  FORMCHECKBOX  Self-care  FORMCHECKBOX  Assistance  FORMCHECKBOX  Other: FORMTEXT       FORMTEXT       Activities of Daily Living Assessment Include specialized body care Consider functioning in last seven daysDocument Source of Information Date and Initial Entries Preliminary and Negotiated Care Plan: What are the individual s strengths, needs and preference? When will care be provided? Who will provide care?Bathing Ability to take bath shower or sponge bath; dry off; transfer in/out of tub/shower  FORMCHECKBOX  Set-up supplies  FORMCHECKBOX  Requires monitoring, encouragement and/or cueing  FORMCHECKBOX  Bathes self, needs help getting in/out of tub shower  FORMCHECKBOX  Requires physical assistance with part of bathing  FORMCHECKBOX  Requires complete bathing  FORMCHECKBOX  1 person  FORMCHECKBOX  2 person assistance  FORMCHECKBOX  Bath bench  FORMCHECKBOX  Transfer bench  FORMCHECKBOX  Tub  FORMCHECKBOX  Shower Frequency:  FORMCHECKBOX  Bed Bath  FORMCHECKBOX  Skin Care  FORMCHECKBOX  Other FORMCHECKBOX  Independent with bathingEating/Drinking Ability to eat/drink food/liquids, including equipment and preferences  FORMCHECKBOX  Requires monitoring, encouragement and/or cueing  FORMCHECKBOX  Requires set up (includes cutting up meat and opening containers)  FORMCHECKBOX  Able to feed self, but requires hands-on assistance to guide or hand food/drink item  FORMCHECKBOX  Able to feed self some foods, but always needs to be fed a meal or part of a meal  FORMCHECKBOX  Must be fed, dependent for all foods/fluids FORMCHECKBOX  Independent, no help or oversight neededNeeds/Concerns  FORMCHECKBOX  Therapeutic diet  FORMCHECKBOX  Supplements  FORMCHECKBOX  Mech altered  FORMCHECKBOX  Adaptive equipment  FORMCHECKBOX  Chewing/Swallowing Problems (choking, coughing, pocketing food, drooling)  FORMCHECKBOX  Weight  FORMCHECKBOX  Loss  FORMCHECKBOX  Gain  FORMCHECKBOX  Food Allergies  FORMCHECKBOX  Food Preferences:  FORMCHECKBOX  Other:  FORMTEXT       FORMTEXT       Treatment, Therapies and Medicines, and Appointments Document Source of Information Date and Initial Entries Preliminary and Negotiated Care Plan: What are the individual s strengths, needs and preference? When will care be provided? Who will provide care?Therapies  FORMCHECKBOX  Speech  FORMCHECKBOX  Occupational  FORMCHECKBOX  Physical  FORMCHECKBOX  Mental Health  FORMCHECKBOX  Respiratory  FORMCHECKBOX  Cardiovascular  FORMCHECKBOX  Daily Management of Pain  FORMCHECKBOX  Health Monitoring  FORMCHECKBOX  Range of Motion/Strength  FORMCHECKBOX  Pressure Ulcers  FORMCHECKBOX  Nebulizer  FORMCHECKBOX  Other:  FORMTEXT       FORMCHECKBOX  No TherapiesMedical Treatment  FORMCHECKBOX  Alcohol/Drug  FORMCHECKBOX  Wound care  FORMCHECKBOX  Feeding Tube Specify: FORMTEXT        FORMCHECKBOX  Chemotherapy  FORMCHECKBOX  Radiation  FORMCHECKBOX  Dialysis  FORMCHECKBOX  Suctioning  FORMCHECKBOX  Tracheotomy Care  FORMCHECKBOX  IV Medications  FORMCHECKBOX  Infections  FORMCHECKBOX  Oxygen  FORMCHECKBOX  Intake/Output Monitoring  FORMCHECKBOX  Catheter Care Type: FORMTEXT        FORMCHECKBOX  Sliding scale insulin  FORMCHECKBOX  Blood glucose monitoring: Frequency: FORMTEXT        FORMCHECKBOX  Other: FORMTEXT       FORMCHECKBOX  No Medical TreatmentSelf Medication/Administration The ability to take one s own medication in a safe and reliable manner. If the level of assistance varies, this should be described in the care plan.  FORMCHECKBOX  For one or more medications needs assistance  FORMCHECKBOX  For one or more medications requires administration See RCW 69.41.010 (11) and RCW 69.41.085 for information FORMCHECKBOX  All medications are independentTransportation/Appointments  FORMCHECKBOX  Requires assistance with setting up appointments or arranging transportation  FORMCHECKBOX  Other: FORMTEXT       FORMCHECKBOX  Independent with transportation and making appointments Significant Behaviors Current and Past Behaviors/ProblemsDocument Source of Information Date and Initial Entries Preliminary and Negotiated Care Plan: Significant Details: Frequency What Triggers the Behavior? What can be done to prevent or address behavior? When will care be provided?Current or Past? FORMCHECKBOX  Hoarding/Squirreling  FORMCHECKBOX  Hiding items  FORMCHECKBOX  Breaking, throws items  FORMCHECKBOX  Injuries staff/others  FORMCHECKBOX  Uses foul language  FORMCHECKBOX  Resistive to care  FORMCHECKBOX  Accuses others of stealing FORMCHECKBOX  No problem identified FORMTEXT       FORMCHECKBOX  Not sleeping at night, up when others are sleeping  FORMCHECKBOX  Wandering  FORMCHECKBOX  Exit Seeking  FORMCHECKBOX  Has left home and gotten lost FORMCHECKBOX  No problem identified FORMTEXT       FORMCHECKBOX  Accidental fires  FORMCHECKBOX  History of arson  FORMCHECKBOX  Unsafe when smoking  FORMCHECKBOX  Unsafe cooking-has left stove on FORMCHECKBOX  No problem identified FORMTEXT       FORMCHECKBOX  Yelling  FORMCHECKBOX  Screaming  FORMCHECKBOX  Inappropriate verbal noises FORMCHECKBOX  No problem identified FORMTEXT       FORMCHECKBOX  Mood swings  FORMCHECKBOX  Manic  FORMCHECKBOX  Depressed  FORMCHECKBOX  Cries frequently or constantly  FORMCHECKBOX  Withdrawn or lethargic  FORMCHECKBOX  Delusions  FORMCHECKBOX  Hallucinations  FORMCHECKBOX  Paranoid  FORMCHECKBOX  Suicidal thoughts or behaviors  FORMCHECKBOX  Injuries self  FORMCHECKBOX  Unrealistic fears or suspicions FORMCHECKBOX  No problems identified FORMTEXT       FORMCHECKBOX  Predatory sexual behavior (seeks vulnerable or unwilling partners)  FORMCHECKBOX  Sexual acting out  FORMCHECKBOX  Sexual aggression  FORMCHECKBOX  undresses in public order to expose self FORMCHECKBOX  No problem identified FORMTEXT       Significant Behaviors Current and Past Behaviors/ProblemsDocument Source of Information Date and Initial Entries Preliminary and Negotiated Care Plan: Significant Details: Frequency What Triggers the Behavior? What can be done to prevent or address behavior? When will care be provided?Current or Past? FORMCHECKBOX  Aggressive/intimidating  FORMCHECKBOX  Manipulative  FORMCHECKBOX  Spitting  FORMCHECKBOX  Verbally abusive  FORMCHECKBOX  Combative  FORMCHECKBOX  Assaultive  FORMCHECKBOX  Eats non-edible objects  FORMCHECKBOX  Inappropriate toileting activity Specify: FORMTEXT       FORMCHECKBOX  No problem identified FORMTEXT       FORMCHECKBOX  Easily worried or anxious  FORMCHECKBOX  Easily irritable/agitated  FORMCHECKBOX  Seeks/demands constant attention/reassurance  FORMCHECKBOX  Unrealistic fears or suspicions  FORMCHECKBOX  Inability to control own behavior FORMCHECKBOX  No problem identified FORMTEXT       FORMCHECKBOX  Repetitive anxious complaints or questions  FORMCHECKBOX  Obsessive about health or body functions  FORMCHECKBOX  Repetitive physical movement/pacing, hand wringing, fidgeting  FORMCHECKBOX  Disrobes FORMCHECKBOX  No problems identified FORMTEXT       FORMCHECKBOX  Medication abuse or misuse  FORMCHECKBOX  Drug or alcohol abuse FORMCHECKBOX  No problem identified FORMTEXT       FORMCHECKBOX  Other: Be specific  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT      I completed this assessment and I meet the qualifications for an assessor stated in WAC 388-76-61050Name:  FORMTEXT      Date: FORMTEXT      Phone:  FORMTEXT        FORMTEXT      - FORMTEXT      Name: FORMTEXT      Date: FORMTEXT      Phone:  FORMTEXT        FORMTEXT      - FORMTEXT      Name: FORMTEXT      Date: FORMTEXT      Phone:  FORMTEXT        FORMTEXT      - FORMTEXT       Preliminary and Negotiated Care Plan Signatures Name of Individual:  FORMTEXT      Date of Original Plan FORMTEXT      Signature:Date: FORMTEXT      Date: FORMTEXT      Date: FORMTEXT      Date: FORMTEXT      Date: FORMTEXT      Date: FORMTEXT      Individual: FORMTEXT      Preliminary Service Plan FORMTEXT      Negotiated Care Plan FORMTEXT      Review FORMTEXT      Review FORMTEXT      Review FORMTEXT      Review FORMTEXT      Provider: FORMTEXT      Preliminary Service Plan FORMTEXT      Negotiated Care Plan FORMTEXT      Review FORMTEXT      Review FORMTEXT      Review FORMTEXT      Review FORMTEXT      Resident Representative:  FORMTEXT      Preliminary Service Plan FORMTEXT      Negotiated Care Plan FORMTEXT      Review FORMTEXT      Review FORMTEXT      Review FORMTEXT      Review FORMTEXT       This form was created by a group of Adult Family Home providers, resident advocates, Washington State DSHS/Aging and Adult Services Administration staff and professional assessors, and was designed to include the elements of an assessment required in WAC 388-76-61020. This is a sample form and not a required form. Assessors and providers can make copies of this form, add to it, and modify it as appropriate. The use of word  individual throughout this document refers to the individual being assessed for long-term care services. PLEASE NOTE: THIS FORM DOES NOT TAKE THE PLACE OF KNOWLEDGE OF RULE AND LAW.     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