Preparation Activities

Appendix

Appendix E - Sample Client Assessment Tool and Care Plan

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Sample 1

Home Care Assessment

Code:   A. General Information

Band/Settlement:
Assessor:
Date (dd/mm/yy):
Place of Assessment: Client's Home | Other (specify)
Information provided by:

Code:   B. Client Profile

Name:
Date of Birth:
Band/Settlement:
Age: Male  |  Female
Address:
Languages Spoken:
Directions:
Other Address:
Provincial/Territorial Health No.:
Telephone Number: Party Line:  Yes # ___ |  No
Band/Inuit Id. No.:
Old Age Security No.:
Do you have a neighbor where messages can be left?
Yes # ___  | No
Name:
Telephone Number:
Marital Status: Single | Married | Common law/Partner | Widowed |
Divorced/Separated  |  Recent Status Change
Referred by:  Self   |  Family  |  Physician
Significant Allergies:
Other:

Code:   C. Persons to Notify in Case of Emergency

Closest Family Member:
Name:
Address:
Telephone Number: Work
Home:
Relation to Client:
Band Office Telephone Number:
Health Centre/Nursing Station Telephone Number:

(Lifeline)
Emergency Response Number:
Name:
Address:
Telephone Number: Work
Home
Relation to Client:
Health Center/Nursing Station Telephone Number:

Code:   D. Client Physicians

Physician:
Location:
Telephone Number:
Specialist:
City:

Code:   E. Living Arrangements

Name:
Lives alone or
Relationship:

Code:   F. Client Statement

Will you tell me what kind of help you need and why you need this help?

Code:   G. Physical Environment

Assessment Data

1. What type of residence does person live in (house, elders'lodge, etc.)
   Does the house have stairs? yes | no
   Comments of assessor and/or client:
   
2. How does the client do the following?
   
   Heat house:      Wood   |  Oil  | Electricity  | Propane  | Other
   Cook:    Wood  | Electricity  | Other
   Get Water: Hauls own water  | Has running water | Family hauls water  | Water delivered
   Toilet Facilities: Flush toilet   | Outhouse  | Chemical toilet  | Indoor Pail
   Laundry: By hand  | Laundromat  | Has own appliance | Other
   Comments of assessor and/or client:

Code:   E. Living Arrangements (Update)

Date: Date: Date:

Code:   F. Client Statement (Update)

Code:   G. Physical Environment (Update)

Date: Date: Date:

Code:   H. Physical Health

Do you have any health problems that limit your normal activity?

1. Diabetes
        What problems does this create of the client?
        WT. | B.P. | Temp. |  Pulse | Resp.
   
2. Arthritis or Rheumatism
       What problems does this create of the client?
        WT. | B.P. | Temp. |  Pulse | Resp.
   
3. Emphysema or Bronchitis
       What problems does this create of the client?
        WT. | B.P. | Temp. |  Pulse | Resp.
   
4. Heart or Circulatory Problems  | Pacemaker
       What problems does this create of the client?
        WT. | B.P. | Temp. |  Pulse | Resp.
   
   
5. Cancer
       What problems does this create of the client?
        WT. | B.P. | Temp. |  Pulse | Resp.
   
   
6. Muscular/Neurological disorders (eg. Effects of Stroke, Epilepsy)
        What problems does this create of the client?
        WT. | B.P. | Temp. |  Pulse | Resp.
   
   
7. Operations
       What problems does this create of the client?
        WT. | B.P. | Temp. |  Pulse | Resp.
   
   
8. Accidents/injuries
       What problems does this create of the client?
        WT. | B.P. | Temp. |  Pulse | Resp.
   
   
9. Other:
      What problems does this create of the client?
        WT. | B.P. | Temp. |  Pulse | Resp.
   

Code:   I. Have you been hospitalized recently?

Yes | No

Recovery Complete or:

• Hospital stays in last 12 months:
• Reason:
• Length of stay:
• Discharge Date:

Code:   H. Physical Health (Update)

Date: Date: Date:

Code:   I. Hospital Stays (Update)

• Hospital stays in last 12 months:
• Reason:
• Length of stay:
• Discharge Date:

Code:   J. Current or Recent Medication

Which drug store do you usually use:

Prescription Drug:

• Type of injections received:
• Non-prescription items:

Dosage/Route:
Purpose:
Physician:
Date Drug Started:

Are any of medications given to you by someone else: yes | no
If yes, who assists you taking which drugs listed above? Treatments: Radiation, Physio, Other:

Code:   K. Do you have allergies?

yes | no
List: (What makes you sick and what type of reaction do you have? ):
Food:
Medications:
Other:

Code:   J. Current or Recent Medication (Update)

Medications:
Date: Date: Date:

Code:   K. Do you have allergies? (Update)

Code:   L. Assessment Data

Assessment Data

1. Nutrition
   What do you eat?
   Are there any foods that disagree with you?
   If yes what food?
   Are you on a special diet? yes | no
   Are you following the diet? yes | no
   Who prescribed the diet?
   Comments of assessor and/or client
   
   
2. Elimination
   Continent: Bowel  |  Bladder
   Occasional Problems: Bowel  |  Bladder
   Frequent Problems: Bowel  |  Bladder
   Incontinent: Bowel  |  Bladder
   Comments of assessor and/or client
   
   
3. Respiration
   Do you have trouble breathing?
   Do you have a persistent cough? (Describe)
   Is oxygen equipment used?
   Do you smoke? yes | no
   Comments of assessor and/or client
   
   
4. Skin and Circulation
   Do you have any skin condition problems?
   Do you have any problems with your hands and/or feet? (check re: foot care)
   Comments of assessor and/or client
   
   
5. Eyesight: Good | Fair | Poor | Partly or totally blind
   Can you see numbers on the telephone?
   Glasses yes | no
   When and Where were glasses obtained?
   Date last seen by eye specialist?
   Comments of assessor and/or client
   
   
6. Hearing Good | Fair | Poor | Partly or totally deaf
   Hearing aid: Right | Left | No
   Type of batteries used and where are they normally obtained?
   Date and Place Hearing Aid obtained?
   Date and Place last hearing test completed?
   Comments of assessor and/or client
   
   
7. Oral/Dental: Own teeth Dentures | Upper | Lower | Partial
   Do you have any problems with chewing, swallowing or sore gums?
   yes | no
   Date last received dentures:
   Comments of assessor and/or client

Code:  L. Assessment Data (Update)

• Nutrition: Date: Date: Date:
  
• Elimination: Date: Date: Date:
  
• Respiratory System: Date: Date: Date:
  
• Skin and Circulation: Date: Date: Date:
  
• Eyesight: Date: Date: Date:
  
• Hearing: Date: Date: Date:
  
• Oral/Dental: Date: Date: Date:

Code:   L. Assessment Data (continued)

8. Mobility/Physical Abilities:
   Do you have difficulty walking? yes | no
   If yes, is the difficulty: Outdoors | Indoors
   How do you get to places you cannot walk?
   Drives self | Taxi | Friend drives | Family drives | Other
   Is there anything else that keeps you from going out and getting about?
   Summary of Aids used: Walker | Cane | Crutches | Wheelchair |
   Prosthesis | Bathroom assists | Other
   Equipment and Aides required:
   Comments of assessor and/or client
   
   
9. Social and Emotional Health
   What type of contact do you have with family, friends, community activities.
   What are some activities you enjoy (interests/hobbies).
   What interests/skills would you like to share? (teach Beading)
   Comments of assessor and/or client
   
   
10. Do you see any of the following:
    
    Community Health Representative | Community Health Nurse |
    Mental Health Worker | Social Worker | Other
    

Code:  L. Assessment Data (Update)

• Mobility/Physical Abilities: Date: Date: Date:
  
• Summary of Aides used: Date: Date: Date:
  
• Social and Emotional Health: Date: Date: Date:
  
• Other support workers: Date: Date: Date:

Code:   M. Activities of Daily Living

Assessment Data

1. Light housework? (dishes, etc.)
   does without help | limited | unable
   Comments of assessor and/or client
   
2. Heavy housework? (floor, etc.)
   does without help | limited | unable
   Comments of assessor and/or client
   
3. Laundry?
   does without help | limited | unable
   Comments of assessor and/or client
   
4. Preparation of hot meals?
   does without help | limited | unable
   Comments of assessor and/or client
   
5. Shopping?
   does without help | limited | unable
   Comments of assessor and/or client
   
6. Personal financial affairs?
   does without help | limited | unable
   Comments of assessor and/or client
   
7. Bathing?
   does without help | limited | unable
   Comments of assessor and/or client
   
8. Care of hair?
   does without help | limited | unable
   Comments of assessor and/or client
   
9. Dressing and undressing?
   does without help | limited | unable
   Comments of assessor and/or client
   
10. Eating/feeding?
    does without help | limited | unable
    Comments of assessor and/or client
    
11. Sleeping?
    no problems | some problems | significant problems
    Currently using medication for sleep? yes | no
    Comments of assessor and/or client
    
12. If you have a telephone can you use it? yes | no
    Comments of assessor and/or client

Code:  N. Family and Friends Who Help Client

Type and Frequency of Help

Code:   M. Activities of Daily Living (Update)

Date: Date: Date:

Code:   N. Family and Friends Who Help Client (Update)

Date: Date: Date:

Code:   O. Permission to Share Information:

Do I have your permission to share the information you have given me with other health care professionals and/or family members and for assessment review? yes | no

Code:   P. Service Agreement:

Recommended services agreed upon by client assessor.

Code:   Q. Case Notes:

Date:
Assessor's Intuitive Observations and other relevant informations.

Code:   O. Permission to Share Information: (Update)

Date: Date: Date:

Code:   P. Service Agreement: (Update)

Date: Date: Date:

Code:   Q. Case Notes: (Update)

Date: Date: Date:

Code:   R. Assessor's Summary:

(Write comments regarding the person's ability in each of the following areas.)

1. Environmental Health (living conditions, household tasks, etc)
   
2. Physical Health (ability to communicate, personal care, etc.)
   
3. Mental Health - (Describe client's level alertness, memory, judgement, attitude, morale, cooperativeness)
   
4. Social/Spiritual Health (support system, spiritual values/beliefs, etc.)
   
5. Referrals recommended:

Code:   R. Assessor's Summary: (Update)

Date: Date: Date:

Code:   S. Assessor's Observations and Comments:

1. Explain any changes that have occurred in the client's circumstances recently. How is this affecting the need for services?
   
2. Are there any special factors that need to be considered if service is provided (confusion, attitude of client, memory loss, etc.)

Code:   T. Recommended Service Based on Contract:

• Nursing Diagnosis/Statement of Problem
• Type and frequency of service required
• Objectives of Service (include timeframe)

Code:   S. Assessor's Observations and Comments: (Update)

Date: Date: Date:

Code:   T. Recommended Service Based on Contract: (Update)

Date: Date: Date: