Nursing Assessment For Home Care Form Page 2

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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
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

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