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    Care of Older Adults Assessment Form

    Uploaded by

    NOYMIE GRACE BALOPEÑOS

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Care of Older Adults Assessment Form

    Uploaded by

    NOYMIE GRACE BALOPEÑOS
    13 views5 pages

    Original Title

    care-of-older-adults-assessment-form

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    Copyright:

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    Download as docx, pdf, or txt
    13 views5 pages

    Care of Older Adults Assessment Form

    Uploaded by

    NOYMIE GRACE BALOPEÑOS

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 5

    Care Of Older Adults Assessment Form

    PHYSICIAN NAME:

    DATE: / / PATIENT: DOB: / / ID#:

    PAIN ASSESSMENT
    Please draw where the patient’s primary pain is located using the
    diagram below:

    Neck Head
    Shoulder

    Thorax Arm

    Trun
    Upper
    Forearm Membe
    Abdome
    r
    Wrist

    Thumb

    Fingers
    Buttoc
    In
    guinal Lower k
    Membe
    r Thigh

    Leg

    Ankle

    Toes
    Foot

    Pain: YES NO Location:

    Comments:

    Treatment Plan:
    Medication(s)

    Under Pain Management: Dr

    Mark the level of Pain


    No Moderat Wors
    Pai e Pain t
    n Pain
    I I I I I I I I I I I
    0 1 2 3 4 5 6 7 8 9 10

    0 2 4 6 8 10

    Physician’s Signature:

    Comments:
    OH-PSNP-457
    October © 2013 CareSource. All Rights
    2013 Reserved.
    Care Of Older Adults Assessment Form
    PHYSICIAN NAME:

    PAIN ASSESSMENT: CPT Cat II – 1125F, 1126F

    OH-PSNP-457
    October © 2013 CareSource. All Rights
    2013 Reserved.
    Care Of Older Adults Assessment Form
    PHYSICIAN NAME:

    DATE: / / PATIENT: DOB: / / ID#:

    FUNCTIONAL ASSESSMENT (circle those that


    apply)
    Cognitive Status: Excellent; Diminished; Dementia; Alzheimer’s; Parkinson; Other:

    Ambulatory Status: Excellent; Good; Fair; Walks with cane; Uses wheel chair or scooter; Able to
    climb stairs; Needs assistance; Amputation R/L – AKA; Prosthetic devices:

    SENSORY ABILITY: (circle all that apply)

    Hearing: Excellent; Good; Fair; Poor; Deaf; Hearing Aids or Device:

    Vision: Excellent; Good; Poor; Uses Glasses; Uses contacts; Cataract(s);


    Glaucoma; Macular Degeneration; DM Retinopathy; Blind

    Speech: Excellent; Good; Poor; Verbal apraxia; Aphasia;


    Dysphonia; Ill-fitting dentures; Abnormal tongue/lip movements

    Touch: Intact; Decreased sensitivity (hot/cold); Numbness

    Smell/Taste: No problem, Some changes:

    ACTIVITIES OF DAILY LIVING – ADL: (circle those that apply)

    Does the patient need help with: Grooming; Dressing; Bathing; Housework; Preparing meals; Feeding;
    Shopping; Toilet Use; Continent (Bowel & Bladder)
    Other:

    ADVANCE CARE PLANNING

    Does the patient have: Advanced Directive (Y) (N) Living Will (Y) (N) Surrogate Decision Letter (Y) (N)

    Date discussed with patient/family member: / / Copy or documented in chart: (Y) (N)

    Physician’s Signature:

    Comments:

    OH-PSNP-457
    October © 2013 CareSource. All Rights
    2013 Reserved.
    Care Of Older Adults Assessment Form
    PHYSICIAN NAME:

    FUNCTIONAL STATUS ASSESSMENT: CPT CAT II – 1170 ADVANCE CARE PLANNING: CPT CAT II – 1157F, 1158F HCPCS - S0257

    OH-PSNP-457
    October © 2013 CareSource. All Rights
    2013 Reserved.
    Care Of Older Adults Assessment Form
    PHYSICIAN NAME:

    DATE: / / PATIENT: DOB: / / ID#:

    MEDICATION REVIEW/LIST (Indicate (Y) yes or (N)


    no)
    Medication Review Completed: (Y) (N) Medication List Completed: (Y) (N)

    Physician’s Signature:

    Comments:

    MEDICATION REVIEW: CPT CAT II – 1160F


    OH-PSNP-457
    October © 2013 CareSource. All Rights
    2013 Reserved.

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