Patient Assessment Form - Complete Home Care Services, Inc.

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COMPLETE HOME CARE SERVICES, INC.

117-03 203rd Street, St. Albans, NY 11412

Tel 718.528.5493 • Email info@chcsny.com
Web https://chcsny.com/

Patient Assessment Form

VISIT INFORMATION

Start of Care	Recertification	Homebound	Follow Up:
Visit Type:	Patient ID Verified	Date:

PATIENT INFORMATION

Patient Name:*	DOB:*	Age:	MRN:	Gender:* M F
Source of Info: Patient Other:			Primary Language:

Reason for Homecare
Assessment Teaching Medication Administration Review Reason for Homecare: Primary Diagnosis:
Other Pertinent History and Surgeries:

Allergies:

Family Religious/Cultural Practices:

Immunizations:

Up-to-date Other

Social / Environmental History

Living Situation: House Mobile Home Apartment Nursing Home Hotel suite / Eff. Other:	Lives With: Single Married Widow Caregiver Domestic Partner Other: # Siblings:	Home Environment Safety Suitable for Care: Yes No (See Skilled Note) Safety Locks Child proof Rx containers Infestation Cluttered Space/Stairs No Smoke Detectors No Fire Extinguisher Scattered Rugs Unsafe Bathroom Oxygen used Unsafe Entry/Exits No Telephone Improper Storage Inadequate: Air Heat Plumbing Elect. Refrig.
Comments:

Vital Signs

Weight: Actual: lbs Stated: lbs	Temperature: °F Per Oral Axillary Temporal	Respiration Rate: / min
Heart Rate: bpm	Blood Pressure: mmHg Arm Site: Right Arm Left Arm Position: Sitting Lying Standing

PAIN ASSESSMENT NPA

Pain Controlled? Yes No	Current Level (0-10):	Acceptable Level (0-10):	Visual Scale: 🙂 😕 😣 😫 😭
Location:		Relief Measures:
Pain Description / Characteristics:

Systems Review (*NPA = No Problem Assessed)

1. Endocrine NPA

Diabetes

Type: | Current FBS:

Thyroid Disorder

Thyroid Details:

Adrenal Disorder

Adrenal Details:

Other

Other details:

Comments:

2. Genitourinary NPA

Urgency Frequency Retention Incont. Hematuria Dysuria

Other Details:

Toilet Trained: Yes No

Catheter:

Indwelling Intermittent External

External Date Placed:

# of wet diapers/day:

Comments:

COMPLETE HOME CARE SERVICES, INC.

117-03 203rd Street, St. Albans, NY 11412

Tel 718.528.5493 • Email info@chcsny.com • Web https://chcsny.com/

Patient Assessment Form

Patient Name:

MRN:

Systems Review (Continued)

3. Cardiovascular NPA

Cap Refill >3s Palpitations Abn Heart Rhythm Abn Sounds Tachycardia Bradycardia Cyanosis Edema Neck Vein Dist. Hypertension Hypotension Pacemaker

Pacemaker Loc:

Other Details:

Pitting: +1 +2 +3 +4

Peripheral Pulses:

RUE: Pres Abs Loc: LUE: Pres Abs Loc:

RLE: Pres Abs Loc: LLE: Pres Abs Loc:

Comments:

4. Psychosocial

Mental/Behavioral: NPA

Alert Lethargic Unresponsive Flat Affect Agitated Anxious Confused

Communication Issues: NPA

Vision

Hearing

Language/Literacy

Aids Used/Needed:

Comments:

Speech: NPA

Slurred Garbled Aphasic

Memory:

Good Fair Poor NPA

Oriented To:

NPA Person Place Time

Comments:

7. GI / Nutrition NPA

Nausea Vomiting Dysphagia Constip. Diarrhea Taut Distended Masses Tenderness Bleeding Ostomy

ABD Girth: | Bowel Sounds: Present Absent

Last BM: | Stools/Day:

Diet:

Feeding: Breast Fed Bottle Fed

Appetite: Good Fair Poor

Enteral Tube Type:
Formula Formula: Interm. Intermittent: Continuous

Weight: Gain Loss

Comments:

5. Neuromuscular NPA

Alert Lethargic Flat Affect Confused Agitated Anxious Spasticity Flaccidity ROM Loss Vertigo Tremors Ataxia Headache Paresis Numbness

Alt. Level of Consciousness
Description:
Paralysis Level:
Seizures Description:
Head Circumference:

Fontanel(s): Bulging Sunken

CVA Shunt Other

Other details:

Sensory Alteration Smell Touch Taste

Comments:

6. Respiratory NPA

Orthopnea

# pillows:

Diminished Wheezes Tachypnea Stridor Rhonchi Retractions Sputum Apnea Mon. Oxygen

Crackles: Coarse Fine

Dyspnea: On Exertion At Rest

Retractions Location:

Cough: Productive Non-Productive

Sputum Description:

Oxygen at: LPM:

Continuous Intermittent Nasal Cannula Mask

DME Co.:

Comments:

8. Integumentary NPA

Dry Diaphoretic Pale Rash Pruritus Petechiae Jaundice Birthmark

Turgor: Good Fair Poor

Wound Findings:

Bruises Abrasion Incision Staples Sutures Laceration Press. Ulcer Burns

Wound Care:

Patient/Caregiver Independent with Wound Care
Wound Clinic MD Office
Other HHA Details:

9. Nursing Care NPA

Skilled Nurse Performing Wound Care/Assessment
see Wound Addendum
Skilled Nurse Administering IG
see IG Addendum

Comments:

COMPLETE HOME CARE SERVICES, INC.

117-03 203rd Street, St. Albans, NY 11412

Tel 718.528.5493 • Email info@chcsny.com • Web https://chcsny.com/

Patient Assessment Form

Patient Name:

MRN:

Access & Infusion Therapy

Access: N/A | Peripheral IV start - Attempts x | Peripheral line in place Gauge: Length: Date/Loc:

PICC / Midline Site: Type: Lumens: Ext. cath length: cm Arm Circumference: cm Meas: Date Placed:

CVAD Site: Type: Lumens: Tunneled Non-tunneled

Accessed Port this SNV | Port access in place: Needle size: gauge inch | Port de-accessed

Access site clean/dry & free of s/sx infection Yes No - Describe:

Infiltration Erythema Leak Occlusion Thrombosis Infusion complete Therapy concluded

Additional Notes:

Equipment and supplies: Medication and IV supplies, Sterile Gloves, IV Dressing Change Kit, Alcohol Swabs, Tubing, Sharps Container, Lab Supplies, caps, bio patches. Progress towards goals: good. Response to therapy: Tolerates therapy without incident.

Dressing / Flush: Access Dressing Change: N/A | Access Flush Pre/Post med: ml NS D5W | Maint Flush: ml NS Heparin: ml

Access flush pre/post lab: ml NS

Antiseptic: Alcohol Betadine ChloraPrep | Dressing: Transparent Gauze & tape

Securement device changed | Extension tubing changed x Lumens

Lab Work: N/A BMP CMP Trough Peak CBC Other:

Specimen obtained from: Peripheral Venipuncture Venous Access Device ml blood discarded

Specimen delivered to:

Rx Properly Stored | Anaphylaxis Kit Exp: | N/A

Pre Medication (dose & time):

Factor: #Lot: Exp. Date: Labeling checked with orders: SN Initial:

Medication: Dose: Volume:

Method of administration: IVP Pump Gravity-flow Controlled INJ Disp. Pump S/N Type Other:

Pump Program #1: Pump Program #2:

INFUSION RECORD (14 ROWS) N/A

TIME	TEMP	PULSE	RESP.	B/P	RATE	(Patient status / condition / comments)

Inventory Completed Adequate supplies Ordering Medication Profile Reviewed: No changes Discharge Plan discussed with patient/caregiver

Plan for next visit

Skilled Intervention Note * (Required - Min 110 chars)

Response to therapy: Tolerates therapy without incident Other:

Communication with: MD Supervisor Other:

Plan: Revisit Date:

Medication: Updated Med Profile Unchanged

🕒 Patient Visit Time: Start: End:

🕒 Lab Time: Start: End:

⏱️ Total Time:

Nurse's Signature:*

⚠️ Click here to sign (Required)

Date Signed:

COMPLETE HOME CARE SERVICES, INC.

117-03 203rd Street, St. Albans, NY 11412

Tel 718.528.5493 • Email info@chcsny.com • Web https://chcsny.com/

Patient Assessment Form

Patient Name:

MRN:

RESPIRATORY / VENTILATOR FLOWSHEET

PMH:

Asthma COPD CHF Bronchitis CKD Pl. effusion MI Other:

Medications:

Albuterol Atrovent Neb MDI Freq:

Corticosteroids Other:

ABG Freq
Q:

Time:
pH:
pCO2:
pO2:
HCO3:
BE:
Lactic:

CXR:

BUN:

Creat:

BNP:

VENT INITIATION

Date:

Time:

Time
Vent mode
Airway w/ type/placement
FIO2
BUR/RR/HZ
VE/VT
PIP/Plat/Amp
PEEP
MAP
Ti

Skilled Intervention Note * (Required - Min 110 chars)

Response to therapy: Tolerates therapy without incident Other:

Communication with: MD Supervisor Other:

Plan: Revisit Date:

Medication: Updated Med Profile Unchanged

🕒 Patient Visit Time: Start: End:

🕒 Lab Time: Start: End:

⏱️ Total Time:

Nurse's Signature:*

⚠️ Click here to sign (Required)

Date Signed:

COMPLETE HOME CARE SERVICES, INC.

117-03 203rd Street, St. Albans, NY 11412

Tel 718.528.5493 • Email info@chcsny.com • Web https://chcsny.com/

Patient Assessment Form

Patient Name:

MRN:

Wound #

Assessment Date

Time

Clinician

1. WOUND TYPE / ETIOLOGY & PRESSURE INJURY STAGE

Etiology: Pressure Injury Diabetic/Neuropathic Venous Arterial/Ischemic Surgical Traumatic Skin Tear IAD/Moisture Other

Pressure injury stage: 1 2 3 4 Unstageable Deep Tissue Pressure Injury N/A

2. LOCATION / BODY MAP

Anatomic site

Laterality

Specific location

Clock position

Selected map region

Click directly on the front or back body map to drop numbered wound markers at the exact wound site. Use laterality, quick regions, and notes together for a precise wound location.

Front view

Back view

Mapped wound markers

Each marker keeps its own front/back position. The marker list is saved and exported to PDF exactly as displayed.

Quick region buttons

Photo / image

Body map view

Marker count

Photo obtained Dressing soiled Saturated

Location / wound description notes

3. WOUND MEASUREMENTS

Measurement	Unit	Method / notes
Length (greatest dimension)
Width (perpendicular to length)
Depth (deepest point)
Surface area (L × W)	cm²	Calculated when length and width are entered.
Undermining	cm
Tunneling / sinus tract	cm

4. WOUND BED / EDGES / PERIWOUND

Granulation

Slough

Eschar

Epithelialization

Wound edge — select all:
Attached Non-attached Rolled/Epibole Macerated Diffuse

Periwound — select all:
Intact Erythema Warmth Edema Induration Maceration Excoriation

COMPLETE HOME CARE SERVICES, INC.

117-03 203rd Street, St. Albans, NY 11412

Tel 718.528.5493 • Email info@chcsny.com • Web https://chcsny.com/

Patient Assessment Form

Patient Name:

MRN:

WOUND ASSESSMENT — CONTINUED

5. EXUDATE / ODOR / PAIN

Exudate amount:
None Scant Small Moderate Large

Exudate type:
Serous Sanguineous Serosanguineous Purulent

Odor after cleansing: Yes No

Pain 0–10

Pain type / timing

Pain intervention

Response

6. INFECTION / COMPLICATION ASSESSMENT

Increased redness Increased warmth Swelling Purulence Increased/new odor Increasing pain Fever/systemic symptoms Red streaking Unexpected bleeding Dehiscence

7. CLEANSING / DEBRIDEMENT / DRESSING / TREATMENT

Cleansing solution / method

Debridement

Primary dressing

Secondary dressing

Packing / filler

Topical / medication

Compression

Offloading / pressure relief

Frequency / next dressing change

Patient tolerance

CLINICAL OBSERVATION & INTERVENTION LOG

Date	Time	Document, Assessment, Vital Signs, Health Care Deficits, Intervention, Response

Skilled Intervention Note * (Required - Min 110 chars)

Response to therapy: Tolerates therapy without incident Other:

Communication with: MD Supervisor Other:

Plan: Revisit Date:

Medication: Updated Med Profile Unchanged

🕒 Patient Visit Time: Start: End:

🕒 Lab Time: Start: End:

⏱️ Total Time:

Nurse's Signature:*

⚠️ Click here to sign (Required)

Date Signed:

COMPLETE HOME CARE SERVICES, INC.

117-03 203rd Street, St. Albans, NY 11412

Tel 718.528.5493 • Email info@chcsny.com • Web https://chcsny.com/

Patient Assessment Form

Patient Name:

MRN:

Skilled Intervention Note * (Required - Min 110 chars)

Response to therapy: Tolerates therapy without incident Other:

Communication with: MD Supervisor Other:

Plan: Revisit Date:

Medication: Updated Med Profile Unchanged

🕒 Patient Visit Time: Start: End:

🕒 Lab Time: Start: End:

⏱️ Total Time:

Nurse's Signature:*

⚠️ Click here to sign (Required)

Date Signed:

Nurse Electronic Signature