8/10/2019 Adult Outpatient Assessment
1/2Z: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
LOWELL GENERAL HOSPITAL
ADULT OUTPATIENT INITIAL ASSESSMENT
(ACU,PRESCREENING)Name/Label
Date TimeID Band in Place
Family Spokesperson/Relationship
andphone#:___________________________________________________________________
Preferred Language:English Other________________________
Interpreter Offered: Name ____________________________ Declined
Interpreter Services
Information Obtained: Patient Significant Other Family Extended
Care Facility
Advanced Directive Health Care Proxy: OnFileInformation Given
Name of proxy ______________________________________________
PCP_________________________
CHIEF COMPLAINT / REASON FOR ADMISSION / PLANNED PROCEDURE:
VITAL SIGNS T P RR BP 02SAT Weight (kg) Height
PAIN LEVEL Current: _____ / 10 Max _____ / 10
Pain related to chief complaint? Yes / No; Acute / Chronic
Patients Pain Goal ___________
Unconscious Patient Assess & document behaviors &
physiologic changes consistent with pain.
Onset
________________________________________________________________
Location______________________________________________________________
Duration______________________________________________________________
Characteristics_________________________________________________________
Aggravating___________________________________________________________
Relieved______________________________________________________________
Treatment_____________________________________________________________
PROBLEMS:
YES
NOALL ERGIES
No Known Allergies
Shellfish Iodine
IV Contrast Latex
ALL ERGIES / 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 reactionsSeverity Codes: (M) Mild (MO) Moderate (S)
Severe
All ergy /Into leran ce Reaction & Severit y Cod es All ergy
/Into leran ce Reaction & Severit y Cod es
PAST MEDICAL HISTORY
Cardiac / Vascular No history Hypertension MI/Angina
Metabolic/Endocrine No history Diabetes Thyroid disease Other
Cardiac disease Heart Failure Pacemaker Defibrillator
PsychiatricIllness No history Depression Anxiety Other
Cardiac surgery Valve replacement VAD Other Musculoskeletal No
history Joint replacement History of falls
PVD Arthritis Other
Respiratory No history COPD Tuberculosis
Pneumonia Asthma Sleep apnea Other Cancer No history Yes If yes,
describe:
GI/GU/GYN No history Hepatitis GYN problems
Kidney Stones GI Bleed Pancreatitis GU problems Surgery No
history Yes If yes, describe:
Kidney Disease GERD Other Prostate Anesthesia Problems
Neurologic No history Dementia Migraines Comments:
Vision/Hearing Problems CVA Seizures Other
EENT Cataracts LMP_______________
Alcohol Intake __________________ Substance Abuse
__________________________________________ Smoking PPD ______Would
you want to speak with someone about this? Yes No
CURRENT MEDICATIONS / HERBS / VITAMINS ( List Prescription,
Over-the-counter Drugs, Vitamin/Mineral Supplements, Herbs, Home
Remedies) Taking no medications
Medication Dose Frequency Time of last dose Medication Dose
Frequency Time of last dose
Comments & focused physical assessment:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Signature:
8/10/2019 Adult Outpatient Assessment
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NAME: MEDICAL RECORD #:
Z: nadmin/Assessment Forms/Adult Assessment Outpatient
ACU,Prescreening 04/16/04 , 06/28/04, 101904 MR# 2002-015 Page 2 of
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FUNCTIONAL SCREEN
PT Orthopedic Surgery OT
________________________________________________
PT Crutches/Walker Speech
____________________________________________
PT Other
PROBLEMS: YES NO
PHYSICALTHERAPYREFERRAL
Date / Time Notified ___________
OT/PT/SPEECHTHERAPYREFERRAL
Date / Time Notified ___________
NUTRITIONAL ASSESSMENTNPO Since _______________________ N
Initial enteral feeding placement
PROBLEMS: YES NO
NUTRITIONREFERRAL
Date / Time Notified: _________
MENTAL STATUS PROBLEMS: YES NO
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 forHarming self
and/or others? Yes No If yes, ask the patient to describe
techniques, methods and/or tools thathave helped to de-escalate
behaviors.
__________________________________________________________________
LEARNING ASSESSMENT PROBLEMS: YES NO
1. Readiness to Learn High Medium Poor2. How Do You Learn
Reading Listening Demonstration
3. Barriers to Learning
Communication Deficit
Literacy
Psychosocial/Anxiety(explain all checked) Language
Hearing/Visual Other None4. Learning Needs Memory deficit
Patient Family Patient Family Disease Treatment
Medications Pain Management
Diet Equipment
Other Check in
function
Surgery
ABUSE ASSESSMENT
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?
SW Yes No Please explain.
_____________________________________
3.
Would you like to discuss this with a member of our staff? SW
Yes No
PROBLEMS: YES NO
SOCIALWORKERREFERRAL
Date / Time Notified:_____________
Domestic Violence Notice Given Yes
VALUE ASSESSMENT PROBLEMS: YES NO
Is there any conflict between your religious/cultural beliefs
that are in conflict with your medical treatment? Yes
NoReligion:
PRELIMINARY DISCHARGE PLANNING PROBLEMS: YES NO
Return home with responsible adultName:
______________________________________
CM Transportation arrangements for discharge
CM Home services anticipated 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
fallsLIVING
SITUATIONCM > 80Yrs living alone Other Escort Home:
Spouse/Significant Other Friends Involved family Uninvolved
familySUPPORT
SYSTEMS Neighbors SW None Other
Date Time Notified:______________
DeferredPatient Conditio n
Completed:
Date / Time / Initial:______________
PROBLEMS: YES NO
ADDITIONAL NOTES:
__________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PreScreening
RN: Date: Time:
