Reynolds Home Care Experience Fall 2014

Assessment Form

Instructions: Each of you will be expected to complete the following assessment form on one of the patients
you see after gathering information with the provider.
1. Patient: Mr/Mrs/Ms ___ (insert first initial of patients last name)
Date of visit_______

Preceptor______

2. Community supports in place (circle or check all that apply)

Formal
Informal
Visiting nurses
Family
Meals on wheels
live-in
Home Health aides
visit
Medical house calls
Neighbors
Social work (case manager)
scheduled
Chaplain
drop in
Hospice
Church volunteers
Other
Other
3. Functional Assessment
Please place a check mark in the column which describes your patients ability to perform the specified task
(can they do this task by themselves(Independent [Ind]), do they need the help of at least on person to perform
that task(Assist), or are they unable to perform the task at all (dependent [Dep]). For example, to evaluate
dressing function
A patient who chooses appropriate clothes and can put on those clothes is independent.
A patient who needs help selecting appropriate clothing and/or needs some help to get dressed would need
an assist.
A patient who cannot select appropriate clothing and/or cannot dress himself is dependent in this function.
Instrumental Activities of Daily Living (IADL)

Travel
Finances
Shopping
Telephone

Ind

Assist Dep

__
__
__
__

__
__
__
__

Ind

Assist Dep

Medications __
Cooking
__
Housecleaning__

__
__
__

__
__
__
__

__
__
__

Activities of Daily Living (ADL)

Ind
Eating
Dressing
Toilet
Bathing

__
__
__
__
Ind

Mobility

__

Assist Dep
__
__
__
__

__
__
__
__

Assist Dep
__

__

4. Home safety assessment

Street access (yard gates, walkway, steps, ramp) list: _____________________

Secured entry (door locked, lobby security) list _______________________
o Entry access (electronic lock, intercom buzzer)list ______________
Heat/cooling (y/n)_____________________________
Telephone access (y/n)______________________
Emergency call system (lifeline, medic-alert, etc)list ______________
Medication administration device (chart, pill box, blister pack, device)list________
Food available (y/n) ____________________
Smoke detectors (y/n)__________________
Clutter(check if present or list)
o Loose rugs __________________________
o Cords _______________________________
o Obstacles ________________________________
Pets (y/n)_________________________________

4. Required Writing Assignment (After The Visit): (Save this Assessment Form for reference)

a. Write a short (250-300 word) essay addressing the following questions for one or both of the patients you visited at ho
i. How does the patient you visited meet the challenges of function limitations?
ii. Which community supports are critical to the patients ability to remain at home?
iii. What surprised you during this visit?
b. Email the essay to the preceptor of your visit (see list in Course Book or VC2000)
c. For questions, email Dr Forciea (Ralston): forciea@mail.med.upenn.edu or Dr Miller (VA): rachel.miller@uphs.upenn