SK1-Skilled Services

SK1-Skilled Services
Initial Assessment and Plan of Care
Mileage
Nurse Name

First NameLast Name
Date of Service

MonthDayYear
Date
Client Name

First NameLast Name
Client Date Of Birth

MonthDayYear
Date
Age
Sex:
Marital Status
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Doctor's Name

First NameLast Name
Doctor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Doctor's Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Religious or Cultural Factors Affecting Care:

Yes: Describe
Height
Weight
Is there a copy at the home?
Where is it located?
The office will need a copy of the DNR. Please send a copy to 2489529944
Advanced Directives

Healthcare Surrogate: Name/Phone:
Allergies:

Yes, List:
Language barrier
Primary Language:

Other
Client can read
Learns best by:
Vital Signs
Temperature
Termperature was administered
Pulse
Pulse was:
Pulse was:
Pulse was:
Respiration
Respiration
Respiration is
Blood Pressure blanks* / blank*
Blood Pressure
Blood Pressure taken:
Was blood pressure taken a second time?
Blood Pressure blanks* / blank*
Blood Pressure
Blood Pressure taken:
Functional Screen
Have you had a recent change of functional and/or gait status change due to injury, surgery, or illness?

Yes; comments

Rows	Independent	Totally Dependent	Help of Another Who Helps - A=Assist S= Setup	Uses Device/Type
Toileting
Transfers
Walking
Dressing
Bathing
Grooming
Bed Mobility
Meal Preparation
Eating
Feeding
Errnads
Appointments
Transportation
Telephone Use
Light Housekeeping

Nurse Initials

Rows	Yes
Glove
Hospital bed
Wheelchair
Oxygen
Bedside commode
Nebulizer
Suction
Shower Chair

Sensory/Perception: Ability to respond meaningfully to pressure-related discomfort.

1. Completely Limited: Unresponsive (does not moan,flinch or grasp) to painful
stimuli, due to diminished level of consciousness or sedation. OR limited ability to feel pain over most of body surface.

2. Very Limited: Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness. OR has a sensory impairment which limits the ability to feel pain or discomfort over ½ of body.

3. Slightly Limited: Responds to verbal commands, but cannot always communicate discomfort or need to be turned. OR has some sensory impairment
which limits ability to feel pain or discomfort in 1 or 2 extremities.

4. No Impairment: Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort
Please indicate appropriate number that matches Sensor/Perception above:
Moisture: Degree to which skin is exposed to moisture.

1. Constantly Moist: Skin is kept moist almost constantly by perspiration urine, etc. Dampness is detected every time patient is moved or turned.

2. Very Moist: Skin is often, but not always, moist. Linen must be changed at
least once a shift.

3. Occasionally Moist: Skin is occasionally moist, requiring an extra linen change
approximately once a day.

4. Rarely Moist: Skin is usually dry. Linen only requires changing at routine intervals.
Please indicate appropriate number that matches Moisture above:
Activity: Degree of physical activity

1. Bedfast: Confined to bed.

2. Chairfast: Ability to walk severely limited or non-existent. Cannot bear own eight and/or must be assisted into chair or wheelchair.

3. Walks Occasionally: Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.

4. Walks Frequently: Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours
Please indicate appropriate number that matches Activity above:
Mobility: Ability to change and control body position.

1. Completely Immobile: Does not make even slight changes in body or extremity
position without assistance.

2. Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.

3. Slightly Limited: Makes frequent though slight changes in body or extremity
position independently.

4. No Limitations: Makes major and frequent changes in position without assistance.
Please indicate appropriate number that matches Mobility above:
Nutrition: Usual food intake pattern.

1. Very Poor: Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement. OR is NPO and/or maintained on clear liquids or I.V.’s for more than.

2. Probably Inadequate: Rarely eats a complete meal and generally eats only about
1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR receives
less than optimum amount of liquid diet or tube feeding.

3. Adequate: Eats over half of most meals. Eats a total of 4 servings of protein
(meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered. OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs.

4. Excellent: Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.
Please indicate appropriate number that matches Nutrition above:
Friction and Shear

1. Problem: Requires mod to max assist in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring
frequent reposition with maximum assistance. Spasticity, contractures or agitation lead to almost constant friction.

2. Potential Problem: Moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair restraints, or other devices. Maintains relatively good position in chair or bed most of the time, but occasionally slides down.

3. No Apparent Problem: Moves in bed and in chair independently and has sufficient
muscle strength to lift up completely during move.Maintains good position in bed or
chair at all times.
Please indicate appropriate number that matches Friction and Shear above:
Braden Risk of pressure ulcer development: 15-16=Low risk 13-14=Moderate risk 12 or less=High risk
Total Score

Rows	Name of kids
Name 1
Name 2
Name 3
Name 4

Rows	Name of grand kids
Name 1
Name 2
Name 3
Name 4

Rows	Name of great grand kids
Name 1
Name 2
Name 3
Name 4

Rows	PERSON CENTERED TOUCHPOINTS
One
Two
Three

Allergies/Reactions

Rows	Vitamins, Over-the-Counter and Herbal Medications	Route, Dose and Frequency
1
2
3
4
5
6
7
8
9
10
11
12

Orders for Discipline and Treatments (Specify Amount/Frequency/Duration)
Goals
Rehab Potential
Discharge Plans
60 Day Summary:
Nurse Name

First NameLast Name
Nurse Email
example@example.com
Nurse Signature
Client/Legally Responsible Person Signature
Physician Name
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Signature
By signing this service plan I acknowledge that I am directing the agency to provide the above listed services to me and that I have the right to temporarily suspend, permanently terminate, temporarily add, or permanently add the provision of any service.
Should be Empty:

Rows	Yes	Type
Mechanical Lift
Walker
Cane
Brace
Incontinence Products
Other:
Supplier

SK1-Skilled Services

Initial Assessment and Plan of Care

Vital Signs

Functional Screen

MEDICATION

Immunizations:

Pain Assessment

Environment/Home Safety

Others involved in Client's Care:

LIFE HISTORY INFORMATION

General

Social

Physical

Purposeful

Rows	Name of Medication	Dose and Route of Administration	Frequency	Indication	Start Date	End Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19