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
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)
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
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