Fillable Printable Nurse Evaluation Form - New York
Fillable Printable Nurse Evaluation Form - New York
Nurse Evaluation Form - New York
Nursing Assessment for Home Care Page 1 of 3
Patient Information:
Last Name: First Name: Middle Initial:
ADAP ID Number: 555- Social Security Number:
Contact Person (Name & Relationship):
Contact Phone (Day-time): Please submit release to allow Program contact.
Living Situation:
Dwelling: Apartment House Other: Floor: # of Rooms: Elevator: Yes No
Lives alone: Yes No Identify all individuals living in the home:
List the services, hours and days they are available and able to assist with care giving:
Hospitalization:
Hospital Name: Address:
Hospitalized: From: To: Diagnoses:
Hospital Contact: Phone:
Patient Status:
Is patient alert? Always Can patient direct a home care worker? Yes No
Sometimes If no, who is responsible for directing home care workers?
Never Name/Relationship:
Patient Height: Patient W eight:
Recent significant weight loss? Yes No If Yes, amount lost:
Impairments:
Muscular/Motor:
Sensory:
None Partial Total None Partial Total
1. Speech
2. Sight
3. Hearing
1. Hand/Arm
2. Upper Extremities
3. Lower Extremities
Cardiovascular / Respiratory:
None Partial Total Describe impact on functional ability.
1. Respiratory
2. Cardiac
3. Circulatory
________________________________________________
__________ __________ __________ __________ ________
1. Does patient have history of tuberculosis? Yes No Pulmonary Extra pulmonary
2. Did patient complete therapy? Yes No
3. Does patient currently have tuberculosis? Yes No Pulmonary Extra pulmonary
4. Is patient currently on tuberculosis prophylaxis? Yes No Hx of TB prophylaxis Yes No
5. Last documented PPD: Date and result ________________ Anergy results if available:____________________
6. If on tuberculosis treatment, are there 3 negative AFB? Yes No Negative chest x-ray Yes No
New York State Department of Health
Uninsured Care Programs Nursing Assessment - Page 2 of 3
Patient Name:______________________________________________________ ADAP ID#: 555-_________________
Agency: ___________________________________________________________ Provider Number: ______________
Mental Status
Never Partial Total Never Partial Total
1. Oriented place and time
2. Anxiety
3. Agitated
4. Short term memory loss
5. Wanders
6, Depression
7. Impaired judgment
8. Danger to: Others (Aggressive)
Self
9. Articulates needs
10. Sleep disorder
11. Abusive to: Others
Self
12. Other Cognitive / Mental
Status Information:
Patient Ability to Take/Administer Medication:
Never Sometimes* Always *Complete #7.
1. Totally independent
2. Needs reminding
3. Non-compliant
4. Needs help preparing
5. Needs administration
6. Patient/care giver can be
taught to administer Yes No
7. Please explain:
If patient is not independent, what arrangements have been made to administer medications?
IV Infusion and Injections: # of Times Per Week
Patient requires home infusion via: ______________
Central Line Peripheral Line
Injections ______________
Blood work (in the home) ______________
Elimination:
Bowel Bladder
Continent
Occasionally Incontinent
Incontinent
Medical Treatment: (Check T all that apply) Please list all medications on AI485:
1. Decubitus care
2. Dressings - Simple
3. Dressings - Sterile
4. Enema
5. Catheter care
6. Monitor vital signs
7. Tube feeding
8. Tube irrigation
9. Suctioning
10. Oxygen administration
11. Blood tests
12. Ambulation exercise
13. Rehabilitative therapy
14. Physical therapy
New York State Department of Health
Uninsured Care Programs Nursing Assessment - Page 3 of 3
Patient Name:_____________________________________________________ ADAP ID#: 555-_________________
Agency: __________________________________________________________ Provider Number_______________
Identification of Service Needs:
W ithout
Help
W ith
Cane
With
W alker
W ith
W h ee lch air
W ith
Personal
Assistance
Unable
Ambulate inside
Ambulate outside
Get up from seated position
Get up from bed
Transfer to:
Commode
W heelchair
Indicate Patient’s Personal Service Needs:
Independent
Partial
Assist
Total
Assist Independent
Partial
Assi st
Total
Assist
Grooming
Dressing
Washing
Bathing
Feeding
Meal Prep
Reheat Meals
Toileting/ Bathroom
Urinal or bedpan
Commode
Catheter
Laundry
Shopping
Housecleaning
Is the patient homebound? Yes No*
*If patient is not homebound, you must submit justification of home care separately.
Certification:
This assessment is based on personal observation of the patient. Yes No
This assessment is based on information relayed to me by: ______________________________________________
Prepared by: (print name)___________________________________________ Phone #:_____________________
Agency Affiliation:_________________________________________________ FAX#: _______________________
Signature:________________________________________________________ Date: ________________________
Is any other agency/vendor providing services in the home to the patient? Yes No
If Yes, Agency Name:___________________________________Services:__________________________________
Have all home care insurance benefits been exhausted? Yes No
Is this patient eligible for Medicaid? Yes No Have they applied to Medicaid? Yes No
If No, state reasons:_____________________________________________________________________________
FOR NEW HOME CARE APPLICANT ONLY:
How was the applicant referred to your agency?
Doctor Social Worker Discharge Planner Location:___________________________________________
Other Please explain:___________________________________________________________________________
(Rev. 12/2005)
