INITIAL ASSESSMENT – NURSING
Patient Name _____________________________ Election Date ___________________ Assessment Date _________________
MR# ____________________________________ Date of Birth ___________________ Age ____________________________
Vital Signs
T ________ Pulse (Resting) ________ Resp ________ BP __________ Weight: ________ MAC__________
Pain Assessment
Intensity: none = 0 1 2 3 4 5 6 7 8 9 10 = most intense Acceptable level: ________ /10
Frequency: occasionally y constantly
Location: ___________________________________________________________________________________________________
Description of pain: ___________________________________________________________________________________________
Nonverbal signs of pain: _______________________________________________________________________________________
Associated symptoms: _________________________________________________________________________________________
C i i i Yes No
Immediate Care & Support Needs: Document patient rating from ESAS assessment
_____ Pain/Comfort Describe ____________________________________________________________________________
_____ Fatigue Describe ____________________________________________________________________________
_____ Nausea Describe ____________________________________________________________________________
_____ Depression Describe ____________________________________________________________________________
_____ Anxiety Describe ____________________________________________________________________________
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_____ Drowsiness Describe ____________________________________________________________________________
_____ Appetite Describe ____________________________________________________________________________
_____ Shortness of breath Describe ____________________________________________________________________________
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_____ Well-being Describe ____________________________________________________________________________
_____ Other Describe ____________________________________________________________________________
Patient’s Primary Concern/Goals
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Caregiver’s Primary Concern/Goals
___________________________________________________________________________________________________________
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Evaluation of Physical, Psychosocial, Emotional and Spiritual Status/Immediate Care Needs
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
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Interventions and Teaching
___________________________________________________________________________________________________________
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Need for Comprehensive Assessment
Nursing Social work Spiritual care Physician Bereavement
Dietitian Physical Therapy Occupational Therapy Speech Therapy
Patient /Caregiver refuses the following services and assessments: _____________________________________________________
RN Signature ______ Date
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TCG–100 © 2008 The Corridor Group, Inc.
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COMPREHENSIVE ASSESSMENT – NURSING
Patient Name ___________________________ MR# ______________ Election Date __________ Assessment Date __________
Date of Birth _________________ Age __________ Hospice Dx ________________________ Is death imminent? Yes No
Level of Care: RHC CC INPT Respite Location: Home Nsg Hm ALF Hospital Bd/care
Admission: Precipitating factors Patient/family subjective complaint(s) ___________________________________________________
In last year (include date, if known):
Hospitalized ________ Pneumonia ________ Aspiration pneumonia ________ UTI ________
Recurrent fever after atb ________ Stage 3–4 decubitus ________ ER visit ________ Hip fx ________
Septicemia ________ Pyelonephritis ________ Unexplained syncope ________ Cardiac arrest/resuscitation_______
Alteration in Comfort Problem: Yes No
Pain as Bad as You
No Pain Mild Pain Moderate Pain Severe Pain Very Severe Pain
Can Imagine
Circle the one number that best fits the patient’s pain at its worst in past week.
0 1 2 3 4 5 6 7 8 9 10
Circle the one number that best describes the patient’s pain right now.
0 1 2 3 4 5 6 7 8 9 10
Circle the one number that best describes the level of pain acceptable to the patient.
0 1 2 3 4 5 6 7 8 9 10
Patient response: Number scale (0–10) pain rating used Wong-Baker Faces pain rating used
ESAS pain assessment: ________ Pt/family goal: __________ Intervention change needed: Yes No
Comment: ___________________________________________________________________________________________________
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What kinds hi g k h p i ’ p i b ( x p h , , ) _____________________________________
__________________________________________________________________________________________________________
Wh ki hi g k h p i ’ p i w (PL x p w lking, standing, lifting)? __________________________________
___________________________________________________________________________________________________________
What treatments or meds is the patient receiving for pain?________________________________________ Effective: Yes No
Barriers to pain management ___________________________________________________________________________________
Describe the pain:
Aching Throbbing Shooting Stabbing Gnawing Sharp Tender Numb
Burning Exhausting Tiring Penetrating Nagging Miserable Unbearable
Nonverbal signs of pain/discomfort:
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Grimacing Moaning Guarded Frowning Restless Increased BP Increased pulse
Poor appetite Perspiring Crying Agitation Rigid posture Jaws clenched Legs drawn up
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On the diagram, shade in the areas where the patient feels pain. Put an X on the area that hurts the most.
Alteration in Urinary Elimination/GU Status __________________________________________________ Problem: Yes No
Output: Good Moderate Poor Minimal Odor ________________________ Color ___________________________
Frequency: Normal Frequent Infrequent No output last 24 hrs Retention______________ Incontinent: Yes No
Catheter _______________________ Type ____________________ Size _____________ Date Foley changed ______________
UTI: Frequent Occasional None in last yr Date of last UTI ________________ Tx ______________________________
Current Medications ____________________________________________________________________ Effective: Yes No
Comment: ___________________________________________________________________________________________________
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COMPREHENSIVE ASSESSMENT – NURSING
Alteration in Bowel Elimination Problem: Yes No
Constipation _____________________________________________Diarrhea _____________________________________________
Incontinence: Yes No Frequency of incontinence_________________________ Bowel sounds _______________________
Colostomy _______________________________________ Ileostomy __________________________________________________
Usual bowel pattern _______________________________________ Last BM ___________________________________________
Current bowel regimen _____________________________________ Effective? __________________________________________
Comment: ___________________________________________________________________________________________________
Alteration in Nutrition/Hydration Dietitian referral needed: Yes No Problem: Yes No
Ht ______ Wt ______ BMI ______ MAC ______ Normal weight ______ Weight gain loss in last ____ months: # lbs_____
Nutrition Intake (% usual daily amt) ___________________ Anorexia Number of meals per day: 1 2 3 4 4+
Pt/family acceptance/understanding of weight loss: Yes No Restricted/special diet ____________ Appetite __________
Tube Feeding: Yes No Type__________ Amt___________ Nausea Vomiting: Frequency _____________________
Dysphagia: Yes No Prevents sufficient intake to sustain life: Yes No Number of dysphagia event in last week: ____
ESAS nausea assessment ________ Pt/family goal ________ Intervention change needed: Yes No
ESAS appetite assessment ________ Pt/family goal ________ Intervention change needed: Yes No
Comment: ___________________________________________________________________________________________________
Alteration in Respiratory Status Problem: Yes No
O2 sat level on RA ______ O2 sat level on O2@ _____ O2 ________ L/min Continuous Intermittent Pt removes/refuses
Breath sounds (Rt) _____________ (Lt)_______________ Quality ___________________________ Orthopnea _______________
Dyspnea: at rest: disabling moderate minimal Dyspnea: on exertion: disabling moderate minimal
Amount of exertion before patient becomes dyspneic: distance amb _______ minutes talking ______ other ______________
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Cough ____________________ Sputum color _________________________ Infections ________________________________
Current Medications ________________________________________________________________ Effective: Yes No
ESAS SOB assessment ________ Pt/family goal _________ Intervention change needed: Yes No
Comment: ___________________________________________________________________________________________________
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Alteration in Cardiac/Circulatory Function Problem: Yes No
Heart sounds __________________________ Pulses ____________________________ Pulse deficit _____________________
Regular rate/volume ___________________________ Hypo/hypertension ______________________ Cyanosis _____________
Chest pain: Yes No Number of episodes in last week _________________ Precipitating factors ______________________
What relieves chest pain? Nitro Rest Other med _____________ Other _____________________________________
Edema RLE Degree _____ Pitting? _____ LLE Degree _____ Pitting? _____ Other location: _______________________
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RUE Degree _____ Pitting? _____ LUE Degree _____ Pitting? _____ Degree ________ Pitting? _____
Current Medications ____________________________________________________________________ Effective: Yes No
Comment: ___________________________________________________________________________________________________
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Alteration in Physical Mobility Problem: Yes No
Weakness AEB __________________________________________ Disability _________________________________________
Ambulation Indep Walker Need assistance Holds furn/walls ROM limitations ______________________________
Ambulation Distance ___________ (steps or feet) Decrease: Yes No Transfer ability: Indep Needs assist
Mainly sit/lie Mainly in bed Totally bed bound Unable to do most activity Unable to do any activity
Family/facility report of in functional ability: ____________________________ AEB_____________________________________
ESAS tiredness assessment ________ Pt/family goal ________ Intervention change needed: Yes No
Comment: ___________________________________________________________________________________________________
ADL Assessment HHA Needed: Yes No Frequency __________
I=Independent P=Partially able N=Needs assistance U=Unable to Do
Feeding Self ________ Transferring ________ Dressing ________ Bathing ________
Toileting _________ Ambulating ________ Sit Independently ________ Prepare Meals ________
Light Housekeeping ________ Personal Laundry ________
Ability of caregiver to assist with custodial needs of patient _____________________________________________________________
Comment: ___________________________________________________________________________________________________
Fall Risk Assessment Circle appropriate item and add scores Problem: Yes No
Hx of falls = 15 Incontinence = 5 Unable to ambulate independently = 5
Confusion = 5 Increased anxiety = 5 Decreased level of cooperation = 5
Age > 65 = 5 Cardio/pulm disease = 5 Meds for HTN or level of consciousness = 5
Impaired judgment = 5 Postural hypotension = 5 Initial admission to hospice/facility = 5
Sensory deficit = 5 Attached equip (IV, O2 tubes) = 5
Score of 15 or higher is considered high risk Patient Score: _________________ High Risk: Yes No
Comment:__________________________________________________________________________________________________
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TCG–110 © 2008 The Corridor Group, Inc.
COMPREHENSIVE ASSESSMENT – NURSING
Alteration in Skin Integrity Problem: Yes No
Wounds/Decubiti ___________________________________ Skin color _________________________________________________
Lacerations _______________________________________ Skin turgor ________________________________________________
Contusions _______________________________________ Skin to touch ______________________________________________
Petechiae ________________________________________ Rash ____________________________________________________
Skin tears ________________________________________ Abrasions _________________________________________________
Comment: ________________________________________ ―W A ‖ i i his assessment: Yes No
Document stage of each pressure ulcer on diagram.
Alteration in Mental/Neurological Functioning Problem: Yes No
Pupils equal _____________________ Disorientation ________________________ Responsiveness _____________________
Cognition _______________________ Level of consciousness ________________ Seizures ___________________________
Syncope ________________________ Headache __________________________ Anxiety _____________________________
Depression __________________________ Memory impairment: Long term Short term Progressing: Yes No
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Vision __________________________ Hearing ____________________________ Sensory impairment __________________
Speech: 6 words or less Yes No One word or less Yes No Nonverbal Yes No
Dysphasia: Yes No Able to smile: Yes No Able to hold head up independently: Yes No
Coma: Abnormal brain stem response: _________________ Absent verbal response Absent withdrawal response to pain
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Current Medications _____________________________________________________________________ Effective: Yes No
ESAS drowsiness assessment: _________________ Pt/family goal: _____________ Intervention change needed: Yes No
ESAS anxiety assessment: ____________________ Pt/family goal: _____________ Intervention change needed: Yes No
ESAS depression assessment: _________________ Pt/family goal: _____________ Intervention change needed: Yes No
Comment: ___________________________________________________________________________________________________
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Alteration in Sleep Patterns Problem: Yes No
Current sleep pattern ______________________________________ Change in pattern
Sedatives used __________________________________________ Effective
Comment:
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Alteration in Endocrine System Problem: Yes No
Diabetes __________________________________________________ Treatment
Current Medications _________________________________________ Effective
Comment:
Vital Signs:
T _________ Pulse (Resting) __________ Resp _________ BP _________ Ascites: Yes No Abdominal girth ___________
Pertinent Laboratory Results (if known): _________________________________________________________________________
Alteration in Coping Problem: Yes No
Signs of psychosocial/emotional distress ________________________________________________________ Pt Caregiver
Signs of spiritual distress _____________________________________________________________________ Pt Caregiver
Signs of family discord/distress ________________________________________________________________ Pt Caregiver
Caregiving environment is adequate to meet patient needs: Yes No Comment _____________________________________
Caregiver expressing anticipatory grief: Yes No Comment _____________________________________________________
DME & Supplies
Medical Supplies and Equipment in home __________________________________________________________________________
Medical Supplies and Equipment needed __________________________________________________________________________
Patient/caregiver to demonstrate equipment use and safety? ___________________________________________________________
Infusion
Type: Peripheral PICC Central Venous Subcutaneous Other: _______________________________________
Location: _____________________________ Date placed: _____________ Size/gauge: ________ Type/brand: ___________
Purpose: Pain mgmt Hydration Antibiotics Maintain venous access Other: _____________________________
Pump: Type: ______________________________ Pump setting: _______________________ Verified w/ orders: Yes No
Comments: __________________________________________________________________________________________________
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TCG–110 © 2008 The Corridor Group, Inc.
COMPREHENSIVE ASSESSMENT – NURSING
Medications
See Medication Profile for current medications List of medications reviewed with patient/representative
Pt able to take medications as prescribed: Yes No Caregiver able to administer medications as prescribed: Yes No
Medications effective: Yes No Unwanted side effects: Yes No
Drug interactions: Yes No Need for pharmacist consultation: Yes No
Reviewed facility orders & Notes New orders found Copy of orders/Notes obtained for hospice chart
Provided written policy on disposal of controlled drugs to patient/family Reviewed drug disposal policy
Eligibility Assessment Prognosis Guideline (LCD) attached for _______________________ (dx)
Patient is eligible for hospice care as evidenced by (AEB). Document comparisons of current status with baseline assessments
(admission or recertification assessments). Reference changes with specific time period. Check all that apply.
Progressive malnutrition: AEB ________________________________________________________________________________
weakness: AEB __________________________________________________________________________________________
function: AEB ____________________________________________________________________________________________
cognitive status: AEB _____________________________________________________________________________________
skin integrity: AEB ________________________________________________________________________________________
Recent infections: AEB ______________________________________________________________________________________
Changes in medications _____________________________________________________________________________________
need for services: AEB ____________________________________________________________________________________
Diminishing lab results: AEB _________________________________________________________________________________
pulmonary function: AEB ___________________________________________________________________________________
cardiac function: AEB _____________________________________________________________________________________
Other: _______________________ AEB ______________________________________________________________________
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Plan of Care
Complications/risk factors affecting care planning ___________________________________________________________________
The plan of care was presented to and discussed with the patient and representative
Level of understanding: Good understanding Partial understanding Do not understand
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Level of ability to participate in care: Good participation Partial participation Cannot participate Decline
Patient/Representative Instructions
Hospice Services Plan of Care How to Contact Hospice Resuscitation Policy
After Hours Services Emergency Procedures Grievance Procedure Bill of Rights
Use of Equipment Infection Control Confidentiality of Records Advance Directives
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Teaching
Understand disease process and signs of disease progression: Patient Yes No Representative Yes No
Caregiver willing and able to receive instructions and provide care: Yes No Comment: ________________________________
Reviewed PoC with: Patient Representative Facility staff __________________________________________________
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Teaching to: Patient Representative Facility staff __________________________________________________
Teaching topics: ______________________________________________________________________________________________
Caregiver expresses confidence in providing care: Yes No Response to teaching: __________________________________
Level of understanding: Excellent ___________________ Good ___________________ Poor ______________________
Communication/Collaboration/Referrals/Need for Comprehensive Assessment
SW ________________________________________________ Spiritual Care ____________________________________
Facility staff _________________________________________ Volunteer Coordinator _____________________________
Aide _______________________________________________ Dietician ________________________________________
Bereavement ________________________________________ Other __________________________________________
Attending Physician:
Reported patient status Reported on plan of care problems, interventions, goals & patient response
Received new order(s) ______________________________________________________________________________________
Consultation results __________________________________________________________________________________________
Summary
Need for Comprehensive Assessment:
Nursing Social work Spiritual care Physician Bereavement
Dietitian Physical Therapy Occupational Therapy Speech Therapy
Patient /Caregiver refuses the following services and assessments: _____________________________________________________
Signature/Title ____________________________________________________ Date ____________________________________
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TCG–110 © 2008 The Corridor Group, Inc.
