NURSING ASSESSMENT/REASSESSMENT Client Last Name Client First Name Date of Assessment Client Date of Birth Age FRA +1 if 65+ Male Female Primary Diagnosis Secondary Diagnosis Tertiary Diagnosis FRA +1 Other Diagnoses Diagnoses Known By Patient Family Primary Caregiver Are Diagnoses Consistent with Last Assessment? Yes No (changes) Recent Hospitalization(s) Significant Medical/Surgical History ALLERGIES Assessed, No Allergies Reported (environmental, drug, food, or otherwise) Allergies Reported Penicillin Sulfa Medications Animal Dander Latex Dust Pollen Bee Stings Milk/Dairy Products Nuts Eggs Other Comments Sees specialist for positive findings (name) FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences) PHYSICAL Eyes Assessed, No Problems Reported Vision Issues FRA +1 Left Right Glaucoma Cataracts Macular Degeneration Legally Blind Glasses/Corrective Lenses Distance Reading Ears Assessed, No Problems Reported Auditory Issues Hard of Hearing Deaf Discharge Hearing Aid Nose & Sinus Assessed, No Problems Reported Nasal Issues Left Right Epistaxis Drainage Congestion Loss of Smell Sinus Problems Neck & Throat Assessed, No Problems Reported Otolaryngology Issues Hoarseness Sore Throat Lesions Oral Assessed, No Problems Reported Oral Issues Upper Lower Dentures Partial Bridge Difficulty Chewing/Swallowing Episodes of Choking Other Mobility No Problems Reported Mobility Issued Reported Uses Equipment (see below) Requires Supervision Fall Within 3 Months FRA +1 Comments Sees specialist for positive findings (name) FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences) Nursing Reassessment (4/16) Page 1 of 8 FRA Page Tally: _____ NY Non-Waiver Patient Onboarding Kit 9/17
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NURSING ASSESSMENT/REASSESSMENT
Client Last Name
Client First Name Date of Assessment
Client Date of Birth
Age FRA +1 if 65+ Male Female
Primary Diagnosis
Secondary Diagnosis
Tertiary Diagnosis FRA +1
Other Diagnoses
Diagnoses Known By Patient Family Primary Caregiver
Are Diagnoses Consistent with Last Assessment? Yes No (changes)
Recent Hospitalization(s)
Significant Medical/Surgical History
A
LLER
GIE
S
Assessed, No Allergies Reported (environmental, drug, food, or otherwise)
Sleep/Rest No Problems Insomnia Disturbance(s) Uses Sleep Aid
Comments
Behavioral health needs are managed? Yes No Referral for Psych Indicated
Sees specialist for positive findings (name)
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
M
EDIC
ATI
ON
MA
NA
GEM
ENT
Assessed, No Medications Reported
Medication(s) Taken (Complete Medication Profile and assess the following)
Four or more prescriptions taken (any type)? Yes No
Does client report compliance with medications? Always Sometimes Never
Does the supply at hand reflect compliance? Yes No
Would the client benefit from a medication box? Yes No
Do any medications require pre-pour/administration? Yes No
If yes, name and relationship of responsible person
Does this person need instruction? Yes No
Are there any diagnoses without a corresponding medication? Yes No
If yes, explanation
Are there any medications without a corresponding diagnosis? Yes No
If yes, explanation
Comments
Sees specialist for positive findings (name)
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
NY Non-Waiver Patient Onboarding Kit 9/17
Client Initials
Nursing Reassessment (4/16) Page 6 of 8 FRA Page Tally: _____
PA
IN
Assessed, No Pain Reported
Pain Location Onset/Duration
Level/Intensity
Ache Prick Throbbing Burning Sharp
Shooting Dull Pulling Other
Is pain impacting level of function? Yes FRA +1 No
What is the current pain regimen?
Is current pain regimen effective? Yes No (reason)
Comments
Sees specialist for positive findings (name)
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
SK
IN
Assessed, No Problems Reported
Dermatologic Issues
History Decubitis Venous Stasis Ulcer Cellulitis Diabetic Ulcer
PVD Slow/Poorly Healing Wound(s)
Current Bruises Scabs Burns Abrasions Lesions
Cellulitis Lacerations Fistula Stoma Keloids
Scars Rash Flushed Parlor Jaundiced
Cyanotic Incision Ashen Dry/Flaky Scaly
Pruritus Erythema Petechiae Decubiti/Wound
Indicate any identifying marks, scars, amputated limbs, and/or wounds/ulcers/lesions/rashes requiring care on the body below:
Comments
Name of individual managing would care, if applicable
Sees specialist for positive findings (name)
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
NY Non-Waiver Patient Onboarding Kit 9/17
Client Initials
Nursing Reassessment (4/16) Page 7 of 8 FRA Page Tally: _____
IMM
UN
IZA
TIO
N
None Refused, Education Provided
Pneumonia (date) Influenza (date) Hepatitis B (date)
Tetanus (date) Other (date)
Comments
Sees specialist for positive findings (name)
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
H
OM
E SA
FET
Y
Supplies, Equipment, Electrical
Extension cord properly used? Yes No N/A
All electrical medical equipment properly grounded? Yes No N/A
Electrical cords and telephone cords safely positioned and in good repair? Yes No N/A
Electrical appliances away from tub/shower? Yes No N/A
Medications stored in safe appropriate place? Yes No N/A
Outdated medications discarded? Yes No N/A
Storage/handling of oxygen and other supplies safe and appropriate? Yes No N/A
Proper storage of hazardous materials? Yes No N/A
Proper storage or handling of food? Yes No N/A
Home Environment FRA +1 If One or More No’s
Skid resistant mats in place? Yes No N/A
Grab bars, tub bench in place? Yes No N/A
Adequate heat/cooling ventilation and light? Yes No N/A
Scatter rugs secured? Yes No N/A
Appropriate footwear? Yes No N/A
Adequate space for care? Yes No N/A
Rooms free from clutter and objects (including pets) that impair mobility? Yes No N/A
Fire/Emergency
Smoke detectors present and working on each level of the home? Yes No N/A
Knowledgeable in accessing emergency assistance? Yes No N/A
Planned escape route from all rooms of the home? Yes No N/A
Smoking safety guidelines followed? Yes No N/A
Has emergency preparedness kit and/or extra medications/supplies? Yes No N/A
Has emergency plan in event of disruption of services? Yes No N/A
Comments
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
FA
LL R
ISK
ASS
ESSM
NT
Fall Risk Assessment Score (FRA total)
FRA total is greater or equal to 5 so client is considered high risk Falls Precaution Sheet Completed
Comments
Sees specialist for positive findings (name)
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
NY Non-Waiver Patient Onboarding Kit 9/17
Client Initials
Nursing Reassessment (4/16) Page 8 of 8 FRA Page Tally: _____
EM
ERG
ENC
Y P
REP
AR
EDN
ESS
Priority Code (Select one. Must be determined by clinician, independent of service hours)
Level 1 High Priority – Requires uninterrupted service(s)/must have care. In case of disaster, every possible effort must be made to provide service(s) to client
Level 2 Moderate Priority – Services may be postponed with telephone contact. A caregiver can provide basic care until the emergency situation improves
Level 3 Low Priority – May be stable and has access to informal supports. Client can safely miss a scheduled visit
Transportation Assistance Level (Select one. Indicates transportation needs during planned regional/statewide evacuation) TAL 1 Non-Ambulatory – Requires transport by stretcher
TAL 2 Wheelchair-Bound – Unable to walk due to physical and/or medical condition
TAL 3 Ambulatory – Able to walk without physical assistance
Flood Zone (if known)
Comments
FOR REASSESSMENT ONLY – The above is different from the previous assessment conducted (differences)
Based upon this assessment (including diagnoses and medication profile), the following precautions should be entered on the Form CMS-485 and aide plan of care (in addition to Standard/Universal):