LSQ – Ellenor Comp Needs Print

Medical History

Last Health Exam

History of Infections

Conditions

Back Aches
Surgeries

Diagnoses

Arthritis
Heart Condition

Allergies

Demerol
Cipro

Details

Admission Profile

Does the resident have active TB?

Does the resident require continuous medical or nursing care?

Does the resident require treatment with physical or chemical restraints, isolation or confinement for behavioral control?

Is the resident capable of actively participating in transferring from place to place?

Is the resident able to participate in social and leisure activities provided?

Behavioral

Conditions

Depressed
Isolated

Details

Cognitive / Mental Function Status

Conditions

Oriented
Alert

Memory

Cognitive Skills for Daily Decision-making / Judgement

Details

Dental

Upper

Lower

Chewing / Swallowing Difficulty

Explain with Details

Elimination Patterns

Bladder

Continent
Self Care
Pads

Bowel

Continent
Self Care

Details

Elopement (example 1)

Elopement Status

Elopement (example 2)

Elopement Status

Does resident exit seek?

Does resident wander frequently?

Does resident become restless or anxious at any time during the day or evening?

Does resident look for anyone or anything (children, spouse, job)?

Does resident have a history of wandering away or getting lost?

Does resident verbalize expressed desire to go home, pack belongings, or stay near exit doors?

Does resident move around freely and independently with or without devices such as wheelchair, walker, etc?

Is the wandering behavior goal oriented as in specific destination in mind, going home, etc?

Does resident receive medications that could increase restlessness or agitation?

Details

Emotional / Depression

Little interest or pleasure in doing things?

Trouble falling or staying asleep, or sleeping too much

Poor appetite or overeating

Thoughts that you would be better off dead, or of hurting yourself

Frustrated / upset by needing to rely on others

Fall History

Last fall occurred on 8/20/20 | 1 fall(s) in the past 60 days

History of orthostatic hypotension

History of blood thinners

Walks on a regular basis

History of vertigo / dizziness

Currently taking blood thinners

Use an assistive device while walking

History of weakness

Physical therapy in the past 30 days

Concerns regarding falls

Fall prevention measures currently in place

Details

Mental Health History

Previous Dementia Diagnosis

History of mental retardation / developmental disability

Psychiatric diagnosis that required in-patient treatment

Nutrition

Recent Weight

Recent Weight Change

Diet

Physician Ordered: No Added Salt | No Concentrated Sweets

Details

Psychosocial

Family

Friends

Faith / Religion

Hobbies

Social Patterns

Recent Losses

Sensory / Communication

Hearing (Right Ear)

Hearing (Left Ear)

Partial
Hearing Aid

Speech

Details

Skin Condition

General Skin Condition

Cuts / Bruises

Wound

Skin Turgor

Open Areas?

Wound has drainage?

Details

Sleep / Rest Pattern

Bedtime

Wake Time

Nap

Needs to be taken to the toilet throughout night

Gets up at night

Special Needs

Needs

Assistive Device(s)

Cane
Shower Chair
Walker

Vision

Vision / Loss of Vision

20/20
Lens Implant
Glasses

Cataract / Lens Details

Lens Implant – Left
Lens Implant – Right

Assistance Needed

Date of Last Eye Exam

Special Exam

Closing Summary

Nursing Recommendation

Special Notes and Instructions

Ellenor Johnson

Comprehensive Needs Assessment

Medical History

Admission Profile

Behavioral

Cognitive / Mental Function Status

Dental

Elimination Patterns

Elopement (example 1)

Elopement (example 2)

Emotional / Depression

Fall History

Mental Health History

Nutrition

Psychosocial

Sensory / Communication

Skin Condition

Sleep / Rest Pattern

Special Needs

Vision

Closing Summary