Adult Outpatient Assessment

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LOWELL GENERAL HOSPITAL
ADULT OUTPATIENT INITIAL ASSESSMENT
(ACU,PRESCREENING)
Date

Time

Name/Label

Family Spokesperson/Relationship and
phone#:___________________________________________________________________

† ID Band in Place

Preferred Language: † English † Other________________________ Interpreter Offered: † Name ____________________________ † Declined Interpreter Services
Information Obtained: † Patient

† Significant Other

† Family † Extended Care Facility

Advanced Directive Health Care Proxy: † On File † Information Given Name of proxy ______________________________________________ PCP_________________________
CHIEF COMPLAINT / REASON FOR ADMISSION / PLANNED PROCEDURE:

VITAL SIGNS

T

P

RR

PAIN LEVEL

Current: _____ / 10

Max _____ / 10

Pain related to chief complaint? Yes / No; Acute / Chronic

BP

Patient’s Pain Goal ___________

Unconscious Patient – Assess & document behaviors & physiologic changes consistent with pain.

02SAT

Weight (kg)

Height

Onset ________________________________________________________________
Location______________________________________________________________
Duration______________________________________________________________
Characteristics_________________________________________________________
Aggravating___________________________________________________________
Relieved______________________________________________________________
Treatment_____________________________________________________________
PROBLEMS: † YES † NO

ALLERGIES

ALLERGIES / INTOLERANCES (Include medication, food, environment, latex, contrast media)

† No Known Allergies

Reaction Codes: (1) Anaphylactic reactions (2) Breathing problems (3) ENT swelling (4) Mental changes (5) GI disturbances (6) Skin reactions
Severity Codes: (M) Mild (MO) Moderate (S) Severe
Allergy/Intolerance
Reaction & Severity Codes
Allergy/Intolerance
Reaction & Severity Codes

† Shellfish

† Iodine

† IV Contrast

† Latex

† No Known Allergies

PAST MEDICAL HISTORY
Cardiac / Vascular

† No history

† Hypertension

† MI/Angina

Metabolic/Endocrine

† No history

† Diabetes

† Cardiac disease

† Heart Failure

† Pacemaker

† Defibrillator

Psychiatric Illness

† No history

† Depression † Anxiety

† Cardiac surgery

† Valve replacement

† VAD

† Other

Musculoskeletal

† No history

† Joint replacement

† Arthritis

† Other

Respiratory

† No history

† COPD

† Tuberculosis

† Pneumonia

† Asthma

† Sleep apnea

† Other

Cancer

† No history

† Yes If yes, describe:

† No history

† Yes If yes, describe:

† PVD

GI/GU/GYN

† No history

† Hepatitis

† GYN problems

† Kidney Stones

† GI Bleed

† Pancreatitis

† GU problems

Surgery

† Kidney Disease

† GERD

† Other

† Prostate

† Anesthesia Problems

Neurologic

† No history

† Dementia

† Migraines

Comments:

† Seizures

† Other

† Vision/Hearing Problems
EENT

† CVA

† Cataracts

† Other
† Other

† History of falls

LMP_______________

Alcohol Intake __________________ Substance Abuse __________________________________________
Would you want to speak with someone about this? † Yes † No
CURRENT MEDICATIONS / HERBS / VITAMINS
Medication

† Thyroid disease

Dose

Smoking PPD ______

( List Prescription, Over-the-counter Drugs, Vitamin/Mineral Supplements, Herbs, Home Remedies)

Frequency

Time of last dose

Medication

Dose

Taking no medications †
Frequency

Time of last dose

Comments & focused physical assessment: __________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________

Signature:
Z:nadmin/Assessment Forms/Adult Assessment Outpatient ACU Prescreening 04/16/04 , 06/28/04, 101904 ; 10/11/05 MR# 2002-015

Page 1 of 2

NAME:

MEDICAL RECORD #:

PROBLEMS: † YES † NO

FUNCTIONAL SCREEN

PT Orthopedic Surgery

OT ________________________________________________

PT Crutches/Walker

Speech ____________________________________________

PHYSICAL THERAPY REFERRAL
Date / Time Notified ___________
OT / PT / SPEECH THERAPY REFERRAL
Date / Time Notified ___________

PT Other
NUTRITIONAL ASSESSMENT
NPO Since _______________________

PROBLEMS: † YES † NO
NUTRITION REFERRAL
Date / Time Notified: _________

N Initial enteral feeding placement

MENTAL STATUS
† Alert
† Disoriented
† Unconscious
† Developmentally Delayed
† Oriented
† Confused
† Combative
† Other
Does the patient demonstrate present behaviors and or have a past medical history that puts him/her at risk for
Harming self and/or others? † Yes † No If yes, ask the patient to describe techniques, methods and/or tools that
have helped to de-escalate behaviors. __________________________________________________________________

PROBLEMS: † YES † NO

LEARNING ASSESSMENT
1. Readiness to Learn
†
2. How Do You Learn
†
3. Barriers to Learning
†
(explain all checked) †
4. Learning Needs
†

PROBLEMS: † YES † NO

†
†
†
†
†

High
Reading
Communication Deficit
Language
Memory deficit
Patient
†
Disease
†
Medications
†
Diet
†
Other
†
Check in
function

†
†
†
†

Medium
Listening
Literacy
Hearing/Visual

Family
†
†
†
†
†

†
†
†
†

† Poor
† Demonstration
† Psychosocial/Anxiety
†Other † None
Patient
†
†
†
†

Treatment
Pain Management
Equipment
Surgery

Family
†
†
†
†

ABUSE ASSESSMENT

PROBLEMS: † YES † NO
S
OCIAL
WORKER REFERRAL
1. Do you feel safe at home? † Yes SW No
If No, Why Not? ___________________________
2. Have you been hurt physically, verbally, emotionally, sexually, or financially exploited by someone within the past year? Date / Time Notified:_____________
SW Yes † No Please explain. _____________________________________
3. Would you like to discuss this with a member of our staff? SW Yes † No
Domestic Violence Notice Given † Yes
VALUE ASSESSMENT
Is there any conflict between your religious/cultural beliefs that are in conflict with your medical treatment? † Yes † No
Religion:

PROBLEMS: † YES † NO

PRELIMINARY DISCHARGE PLANNING
† Return home with responsible adult
Name: ______________________________________
CM Home services anticipated

PROBLEMS: † YES † NO

LIVING
SITUATION
SUPPORT
SYSTEMS

CM Transportation arrangements for discharge
CM Return to previous facility

† Alone

CM

Assisted Living

CM

Elder Services/VNA

SW

Homeless

CASE MANAGEMENT REFERRAL

† With Family/Friends

CM

Nursing Home

CM

Group home

CM

History of falls

Date Time Notified:______________
Deferred→Patient Condition
Completed:
Date / Time / Initial:______________
PROBLEMS: † YES † NO

CM > 80Yrs living alone
† Spouse/Significant Other

† Other

Escort Home:

† Friends

† Involved family

† Uninvolved family

SW None
† Other
ADDITIONAL NOTES: __________________________________________________________________________________________________________________
† Neighbors

____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
_____________________________________________________________________________________________PreScreen
Date:
Time:
ing RN:
Z: nadmin/Assessment Forms/Adult Assessment Outpatient ACU,Prescreening 04/16/04 , 06/28/04, 101904

MR# 2002-015

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