Documents / Notes / Care Plan Date Yes /No Comment
1 Register Complete up to date
2 Next of Kin details complete and up to date
3 Doctor's Notes complete and up to date
4 Medication Kardex completed and up to date
5 Personal Profile details complete and up to date
6 Comprehensive ADL assessment complete and up to date
7 Screening Page complete and up to date
8 ADL Map Page complete and up to date
9 Care Plan complete and up to date
Activities of Daily Living Date Yes /No Comment
1 Communication needs up to date
2 Controlling Body Temp needs up to date
3 Safe Environment details up to date
Fall risk assessment complete and up to date
4 Mobility needs up to date
Manual Handling assessment complete and up to date
5 Personal Care needs up to date
Barthel assessment complete and up to date
5 Skin Integrity assessment up to date
Waterlow Assessment complete and up to date
Skin assessment complete and up to date (if required)
Wound assessment and up to date (if required)
6 Pain (if indicated)
Pain assessment complete and up to date (if required)
7 Breathing & Circulation needs up to date
8 Nutrition Status up to date
Dietary needs and assessment complete and up to date
9 Elimination details up to date
10 Self Image details up to date
11 Recreational & Social details up to date
12 Rest & Sleep details up to date
13 Dying & Spirituality details up to date
14 Other, if indicated and include, complete and up to date
Data collection taken by:Date of Data colection:
Assessment Date
ADL Signature of Assessing Nurse
1 Communication
SPEECH
1. Normal Function
2. Dysarthria / Dysphasia
3. Loss of ability due to Cognitive Dysfunction
HEARING
1. Normal Function
2. Hearing Impairment, Use of hearing aid NA / N / Y (specify)
3. Deaf
VISION
1. Normal
2. Impaired, Use of Spectacles NA / N / Y, (specify)
3. Blind
EMOTIONAL STATE
1. Alert
2. Orientated
3. Confused
4. Anxious
5. Apathetic / Depressed
6. Agitated
7. Content
8. Challenging Behaviour
COGNITIVE STATUS
1. Mini mental test score MMSE (if indicated)
2. Depression score (if indicated)
3. Other relevant details: known to CPN, Old Age Psyhchiatry
Care Plan N / Y
Assessment Date
ADL Signature of Assessing Nurse 2 Controlling Body Temp
1. Independent
2. Assisted
Care Plan N / Y
3 Safe Environment
1. Independent
2. Assisted
3. Risk of Fall; , see Fall Risk Assessment CANNARD
3-8 Low risk; 9-12 Medium risk; 12+ High risk
Care Plan N / Y
4 Mobility; see Manual Handling Assessment chart
1. Independent
2. Assisted
2a. Walking, 2b. Transfer, 2c. In / Out Bed, 2d. Aids used, specify
3. Chair / Bedfast,
4. Hoist, see Manual Handling Assessment chart
Physio / Physical therapy referral NA /N / Y
Care Plan N / Y
5 Personal Care & Skin Integrity
Barthel; Independent, Low, Medium, High, Maximum
Waterlow; 10+ At Risk; 15+ High Risk; 20+ Very High Risk
PAC AID -Specify, e.eg Mattress, Cushions, Turn Chart etc
Hygiene & Dressing
1. Independent
2. Assisted
Skin Integrity, complete Skin Assessment if indicated
1. Skin Integrity; Intact Yes / No. If NO see Skin Assessment
2. Dry ; 3. Red;
4. Wound(s), Pressure Ulcers, Surgical, Other
Wound Assessment Y / N
Treatment Plan, See Care Plan
Care Plan N / Y
Assessment Date
ADL Signature of Assessing Nurse
6 Presence of Chronic Pain
1. No Pain
2. Moderate Pain
3. Severe Pain
If Chronic Pain identified specify as follows
Site
Duration
Effect on daily life
Treatment & Management, e.g. Analgesic, Positional, Massage
Pain Scale Assesssment completed N / Y
Care Plan N / Y
7 Breathing & Circulation
PMH of Cardiac, Respirarory or Circulatory Disease
Respirations RPM
Base line O2 Sats
Blood Pressure BP
Pulse BPM
Colour, Palour, Breathing Pattern
Use of ; inhaler-(specify); O2; nebs; etc
Positioning
(Ex) Smoker N / Y
Resident informed of Smoking Policy NA / N / Y
Care Plan N / Y
Assessment Date
ADL Signature of Assessing Nurse 8 Nutrition Status
Height (mts)
Weight (kgs)
BMI
MUST
1. Usual diet & appetite etc.
2. Any recent weight loss or gain N / Y
MUST Assessment if indicated
3. Likes & Dislikes
Likes
Dislikes
4. Special diet, specify
Care Plan N / Y9 Elimination
A. Urinary1. Voiding normally
2. Incontinent of urine N /Y, e.g, stress, occasional, continous
3. Daytime N / Y
4. Nightime N / Y
5. Assessment required NA / N / Y
5.a. Assessment completed and submitted to HSE, Date
6. Incontinence aids used specify
7. Catheter, size ____ type _____ site ______
8.. Date last changed
B. Bowel Pattern1. Continent
2. Incontinent
3. Frequency of motions
4. Prone to constipation
5. Normal Bristol Score Stool
6. Any known bowel diorders e.g. Diverticular, haemorroids
C. History of apperient useSpecify
Care Plan N / Y
Assessment Date
ADLSignature of Assessing Nurse
10 Self ImageDetail relevant information regarding Resident's sense of selfPreferred style in dress
Care Plan N / Y11 Recreational & Social
Previous / Present Occupation
Hobbies / Interests
Family Involvement
Social interaction with family & staff
Preferred activities e.g. outings, Sonas etc.
Activity program plan
Care Plan N / Y12 Rest & Sleep
Normal sleeping patternLikes to go to bed atLikes to get up atDaytime rest N / Y
Aids to sleepChemical / Environmental / AlternativeSpecify:
Care Plan N / Y13 Spirituality & Dying
Personal Beliefs
Religion (specify if resident wishes)
Pastoral care needs & wishes
Fears and wishes of resident & family
Expectation of resident and family with regard to LTC
Care Plan N / Y
Assessment Date
ADL Signature of Assessing Nurse Other Relevant Information
ADL Care Plan Map for Activities of Living CP Number
Circle current status as assessed
1 Communication1. Speech, 2. Hearing, 3. Vision, 4. Emotional, 5. Cognitive.
2 Controlling Body Temp1. Independent, 2. Assisted
3 Safe Environment1. Independent 2. Assisted
Risk of Fall; LOW, MEDIUM, HIGH
4 Mobility1. Independent, 2. Assisted
Manual Handling Assessment & Guidelines
5 Personal Care & Skin IntegrityBarthel; Independent, Low, Medium, High, Maximum dependency
Waterlow; 10+ At Risk; 15+ High Risk; 20+ Very High Risk
Skin Integrity, Intact Y / N Wound assessment Y/N
6 Pain, if indicated
7 Breathing & CirculationBlood Pressure BP
Pulse BPM O2 Sats
Respirations RPM Smoker Y / N
8 Nutrition Status Weight Kgs BMI
Height Mts MUST
9 Elimination
Urinary function
Bowel function Apperients Y / N
10 Self Image
11 Recreational & SocialActivity Plan
Hobbies / Interests
12 Rest & SleepPattern / Aids, Chemical, Environmental, Alternate
13 Spirituality & DyingSacrament of the sick Y / N
14 Other: (specify)
RN signature
Resident / Representative signature:
Date
Any other comments:
Register Personal DetailsNumber
Surname
First NameDate of BirthPrevious Address
NationalityOccupation (previous)Marital StatusReligion (if disclosed)
PPS No:GMS No:
Ward of Court N / YYES - Details
Next of Kin contact detailsNameRelationshipAddress
Contact No(s):
GP NameGP address
GP phone & fax No:
MDT involved in care e.g. Psychiatrist, OT, Physio / Physical Therapist, Dietician etc.
Social & Care Summary
Medical History Summary
Known Allergies:
Activities of Living
1 Communication
1. Speech
2. Hearing
3. Vision
4. Emotional State
5. Cognitive Status
2 Controlling Body Temp1. Independent2. Assisted3. Current Temperature
3 Safe Environment1. Independent2. Assisted
3. Risk of Falls; CANNARD Low, Medium, High
4 Mobility1. Independent2. Assisted3. Chair / Bedfast4. Hoist or other Aids, specify
5 Personal Care & Skin IntegrityBarthel; Independent, Low, Medium, High, Maximum dependency
Waterlow; 10+ At Risk; 15+ High Risk; 20+ Very High RiskSkin Integrity; Intact Y / NIf No, specify; Wound(s), Pressure Ulcer, Surgical, OtherCurrent Treatment:
6 Pain, presence of (if indicated)
Site & Severity:Effect on daily livingTreatment & Management
7 Breathing & Circulation Blood Pressure BP
Pulse BPM O2 SatsRespirations RPM Smoker N / Y
PMH of Cardiac or Respiratory disease
8 Nutrition Status Weight Kgs BMI Height Mts MUST Score
Likes and DislikesLikes Dislikes
Special Diet, specify
9 Elimination Urinary function Continent Y / NPMH of bladder disorder e.g. prostate problems, UTI's
Bowel functionNormal Bristol Score Stool Apperients N / Y, specify:Frequency of motions Continent Y / NPMH of bowel disorder,e.g. diverticular, haemorrhoids, IBS, constipation
10 Self Image Summary
11 Recreational & SocialHobbies / InterestFamily involvementSocial interaction with family & staffPreferred activities e.g outings, reading, Sonas etc.
12 Rest & SleepNormal sleeping patternDaytime rest N / Y
Aids to sleepChemical / Environmental / AlternativeSpecify:
13 Spirituality & Dying
Personal beliefs, Religion (if resident wishes to disclose)
Pastoral needs & care
Wishes and fears of resident & family
Expectation of resident, NOK & family
Sacrament of the sick N / Y, Date
Other relevant information
NOK notified of Transfer N / Y
Reason for Transfer
Date & Time
Notes /Comments
RN Signature