Initial Assessment

Comprehensive Initial Assessment

Emeritus Home Care
Nurse Email (DO NOT EDIT)
example@example.com
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Marital Status*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medicaid ID*
Payer Source*
Medical Diagnosis*
Approved Hours Per Day*
Approved Days Per Week*

Vitals
Temperature (°F) *
Respiration*
Systolic*
Diastolic*
Pulse*
Height (feet)*
Weight (lbs)*
Was there recent weight gain?*

YesNo
Was there recent weight loss?*

YesNo

Allergies
Select All That Apply*

None Known AllergiesSeasonal AllergiesPet AllergiesFood AllergiesMedication Allergies
If any allergies, please list:

Vaccination Status
Pneumonia Vaccination Received*

YesNoUnknown
Date, if received

MonthDayYear
Date
Flu Vaccination Received*

YesNoUnknown
Date, if received

MonthDayYear
Date
Tuberculosis Status*

Client has been diagnosed or currently has TBClient has not been diagnosed with TBUnknown

Cardiovascular Assessment
Cardiovascular Assessment (Select All That Apply)*

Low Blood PressureHigh Blood PressureChest PainPacemakerHeart AttackHeart DiseaseEdema (put where in box below)Member Denies ProblemsOther

Vascular Assessment
Vascular Assessment (Select All That Apply)*

Arteriovenous Fistulas (AVF)Vascular GraftCardiacCatheterMember Denies ProblemsOther

Genitourinary Assessment
Genitourinary Assessment (Select All That Apply)*

Normal UrinationDecreased UrinationMastectomyFrequent UrinationPainful/Discomfort UrinationHysterectomyOther

Endocrine Assessment
Endocrine Assessment (Select All That Apply)*

ThyroidHyperglycemiaDiabetesHypoglycemiaMember Denies ProblemsOther

Musculoskeletal Assessment
Musculoskeletal Assessment (Select All That Apply)*

FractureJoint ReplacementAtrophyMusculoskeletal PainOsteoporosisContracture JointsDecreased Range of Motion (ROM)Member Denies ProblemsOther

Medically Frail and Fragile

A Medically Frail or Fragile person is someone with a disabling mental disorder, chronic substance abuse disorder, serious and complex medical conditions, physical/intellectual/developmental disability that significantly impair, has difficulty to perform one or more activities of daily living, disability determination based on Social Security Administration criteria, HIP members who are determined to be medically frail are eligible for enhanced benefits for dental, vision, chiropractic and Medicaid Rehabilitation Option (MRO) Services
Is the client deemed medically frail or fragile? If yes, explain the clinical reason why. If not explain the reason why the client is not medically frail or fragile.*
What services is the client interested in the agency providing: Nurse needs to document services the client is requesting.*
Client Name*

First NameLast Name
Client Signature*

Clear
Date*

MonthDayYear
Date
Registered Nurse Name*

First NameLast Name
Registered Nurse Signature*

Clear
Date*

MonthDayYear
Date

Medication Profile

Medications*

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Nurse Signature*

Clear
Date of Review*

MonthDayYear
Date

Comprehensive Summary of Initial Assessment
Please write a very detailed and descriptive summary of your visit*
Registered Nurse Name*

First NameLast Name
Registered Nurse Signature*

Clear
Date*

MonthDayYear
Date

Service Care Plan

Emeritus Home Care
Client Name*

First NameLast Name
Services Provided*
Medical Diagnosis*

Services Requested
Hours Per Day*
Days Per Week*
Please write a detailed description of what the client is expecting from our services, please include their requested duration. (e.g., I would like someone to come by x hours for x days to help me with _______________)*
Goals of the Services
Please write a detailed description of what the client's purpose or long-term goals of receiving our services is. *
Objectives of the Service
Please write what the client's short term objectives are to achieve the goals of the service.*

Treatments
Is the client currently receiving any services from other skilled healthcare providers in their home? (Physical Therapy, Occupational Therapy, Skilled Nursing)?*

NoYes, please state

Equipment
Does the client have any specific equipment or assistive devices currently in use in their home?*

NoYes, please state

Functional Limitations*

Instrumental Activities of Daily Living (IADL)CommunicationMobilityActivities of Daily Living (ADL)Sensory FunctionCognitive FunctionOther

Updates and Changes
Are there any updates or changes related to the member's services that they are currently receiving? (These are updates and changes related only to the services Emeritus Home Care is providing)*

Yes, there were changes to the service durationNoNew Member
If yes, please elaborate

Discharge Plan
In consideration of potential changes in the member's care needs, it is crucial for us to develop a discharge plan. In the member's own words, please provide a clear statement of their plans in the event that services are no longer available. *

Supervisory Visits
To ensure the ongoing quality and effectiveness of our care services, supervisory visits are conducted periodically. Kindly discuss with the client the purpose and frequency of supervisory visits based off the type of service they are receiving from us.*

Skilled Nursing Services: Supervisory Visits will occur every 62 days and an updated Care Plan when a client's condition change.Personal Care Services: Supervisory Visits will occur every 92 days and an updated Care Plan when a client's condition change.Companion Services: Supervisory Visits will occur every 122 days and an updated Care Plan when a client's condition change.

Acknowledgement
By signing below, the undersigned confirms understanding and acceptance of the Service Care Plan developed by the organization's Registered Nurse (RN), as the guiding framework for all personnel delivering Personal Care, Companionship, or Skilled Nursing services through Emeritus Home Care.

The undersigned acknowledges that the RN will conduct the Initial Assessment before formulating the Service Care Plan. Following the RN's completion of the assessment, the Service Care Plan will be developed within 48 hours. The Service Care Plan is expected to be finalized within 7 working days of the initial service being provided in the member's residence. The RN is accountable for recording any changes to the Service Care Plan, ensuring that the plan accurately reflects the evolving needs of the member.

It is agreed and understood that Emeritus Home Care staff members will only provide services strictly within the defined scope of the Service Care Plan. Any services or takss beyond the outlined plan will be considered outside the scope of Emeritus Home Care's services.

Service Care Agreement Updates:

The agency administrator will update the Service Care Agreement to reflect any changes made to the Service Care Plan by the RN.

Agency Administrator: Earlinda Shaw-Akanni

Agency Contact Number: 678-765-7544
Client Name*

First NameLast Name
Client Signature*

Clear
Date*

MonthDayYear
Date
Registered Nurse Name*

First NameLast Name
Registered Nurse Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

1. Abnormal Color	8. Lesions
2. Body Piercing	9. Rashes
3. Bruises	10. Scars
4. Decubitus	11. Skin Tear
5. Dryness	12. Tattoos
6. Inciscions	13. Other (List Below)
7. Lacerations

	Ok	Hazard	Notes
Small rugs are tacked down or slip resistant
Flooring/rugs/boards are in good repair
Cords are not stretched along pathways or under rugs
Door sills are low
Pathways are free of clutter

	Ok	Hazard	Notes
The handrails are secure and extend from top to bottom
Steps and flooring are in good condition
Steps have non-skid surface
Steps are evenly spaced to allow sure footing
There are no items cluttering in steps

	Ok	Hazard	Notes
Bathtubs and showers have non-skid mats or surfaces
Grab bars are present and accessible
A shower chair is used
The toilet's height is appropriate and easy to get on and off

	Ok	Hazard	Notes
Regularly used dishes and food are placed within easy reach
If needed, the step stool is sturdy with a handrail

Comprehensive Initial Assessment

Vitals

Assistive Devices

Diet

Allergies

Vaccination Status

Sensory Assessment

Psychological and Cognitive Assessment

Neurological Assessment

Cardiovascular Assessment

Vascular Assessment

Respiratory Assessment

Genitourinary Assessment

Gastrointestinal Assessment

Endocrine Assessment

Musculoskeletal Assessment

Other Issues

Skin Assessment

Physical Findings

Wound Assessment

Pain Assessment

Social Assessment

Home Safety Assessment

Side Rails Assessment

Medically Frail and Fragile

Medication Profile

Comprehensive Summary of Initial Assessment

Service Care Plan

Services Requested

Goals of the Services

Objectives of the Service

Treatments

Equipment

Personal Care Tasks

Updates and Changes

Discharge Plan

Supervisory Visits

Acknowledgement

	Ok	Hazard	Notes
Exits/Hall/Stairway/Pathways are well lit
Lights can be turned on before going through a dark area
Night lights are used in hallways, bedroom, and bath
A working flashlight is available in case of power outage
There is a light or light switch within reach of the bed

	Ok	Hazard	Notes
Bed is proper height
Furniture is arranged to prevent tripping

	Ok	Hazard	Notes
There is a working phone by the bed
Emergency numbers are posted and can be seen

	Ok	Hazard	Notes
Outside porch light is working
Outside stairs are in good repair and have a handrail
Outside steps have non-slip surface
Sidewalks and steps are free of debris and snow
Sidewalks and steps are in good condition

	Ok	Hazard	Notes
Smoke and carbon monoxide detectors are present and checked twice yearly
Canes, walkers, and wheelchairs are clean and in good shape
Windows and door are in good repair, easy to use and airtight

	Yes	No
Have there been any instances of falls or attempts to exit the bed without assistance?
Does the client have a history of confusion or disorientation?
Can the client move independently or with minimal assistance?
Is the member non-ambulatory?
Does the client have poor bed mobility or difficulty moving to a sitting position on the side of the bed?
Does the client have alteration in safety awareness due to cognitive decline?
Does the client have the cognitive ability to understand the purpose of side rails and follow instructions about their use?
Are there any concerns about the client attempting to climb over the side rails?
Does the client have a history of falls?
Does the client have difficulty with balance or poor trunk control?
Does the client have difficulty with postural hypotension?
Is the client on any medications that may require safety precaution?
Is the client currently using side rails for support or positioning?
Has the client expressed a desire to have side rails raised while in bed for safety and/or comfort?
Has the client requested that the side rails not be released while sleeping?
Is the client visually challenged?

	Satisfied	Not Satisfied	Notes
Oriented to person, time, and place
Environment is safe and clean
Visual difficulties
Hearing difficulties
Speech or language barriers
Understand or follow instructions
Able to ambulate safely with or without device
Risk for elopement
Chronic conditions/pain/illness/disability
Able to use telephone
Able to manage finances
Social support system
Able to self-administer medications
Possesses functional limitations
Presence of risk factors in environment or with other residents
Susceptible to abuse by others in home environment
Able to report abuse or neglect concerns
Client at risk for abusing other vulnerable adults

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	Mon	Tues	Wed	Thurs	Fri	Sat	Sun
Grocery Shopping
Light Housekeeping
Transportation to Doctor
Community Integrations
Meal Preparations
Feeding
Laundry
Empty Trash

	Mon	Tues	Wed	Thurs	Fri	Sat	Sun
Dressing/Grooming
Ambulation/Mobility
Transfers
Toileting Assistance
Diaper Changes
Vital Signs
Cut Nails (Non-Diabetic)
Oral Hygiene
Hair Care
Bath/Shower
Apply Lotion

	Mon	Tues	Wed	Thurs	Fri	Sat	Sun
Medication Management
Bowel Program
Wound Care/Ostomy Management
Urine Catheter
Tube Feeding
Insulin Injections
Vital Sign Management
Decubitus/Ulcers or Skin Disorder Management
Patient Education Services
Pain Management

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