Older Person's Assessment Form. Name: Contact details: Provide detail: Detail: Detail: Detail: Detail:
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1 BASELINE: COGNITION REVIEW: COGNITION Residents details Resident name: Gender: NHS No: Age: Religion, Spirituality: Older Person's Assessment Form Care Home details Phone number: Address: Date of admission: Details of GP (in case clarification required regarding medication, PMH): Any drug allergies? Yes / No Please list: Next of Kin Information Is there legal Power of Attorney for: Relationship: Contact details: Relationship: Contact details: Health and Welfare Contact details: Yes / No Property and Finance Contact details: Yes / No COMPLETE WITH BASELINE INFORMATION UPON ADMISSION UPDATE WITH REVIEWS AND ANY CHANGES Cognition Is there a DOLS in place? Is there a history of challenging behaviour? Provide detail: Detail: Detail: Detail: Detail: Are there any safeguarding concerns? Comments/Actions: Detail: Detail: Detail: Detail: In partnership with: London Ambulance Service NHS Trust Sutton Community Health Services Page 1 of 10 V2 APRIL 2017
2 BASELINE: HOSPITAL ADMISSIONS REVIEW: HOSPITAL ADMISSIONS Have there been any admissions to hospital in the last 12 months? Reasons: Reason: Reason: Reason: Reason: Outcomes: Outcome: Outcome: Outcome: Outcome: Reason: Reason: Reason: Reason: Reason: Reason: Reason: Reason: Outcome: Outcome: Outcome: Outcome: Outcome: Outcome: Outcome: Outcome: Reason: Reason: Reason: Reason: Reason: Reason: Reason: Reason: Outcome: Outcome: Outcome: Outcome: Outcome: Outcome: Outcome: Outcome: Page 2 of 10
3 BASELINE: GP VISITS AND PAST MEDICAL HISTORY REVIEW: GP VISITS AND PAST MEDICAL HISTORY Were there any recurrent episodes of illness identified from the reasons for hospital admission or recent GP visits? Reasons: Reason: Reason: Reason: Reason: Past medical history: Outcome: Outcome: Outcome: Outcome: Previous delirium Any other recent illness or treatment that didn t require hospital admission? Details: Details: Details: Details: Details: GP Management Plan for Long-term conditions Does the person have an agreed GP Management Plan? If yes, please list the long-term conditions Page 3 of 10
4 BASELINE: OBSERVATIONS REVIEW: OBSERVATIONS BASELINE: MEDICATIONS REVIEW: MEDICATIONS Medications Please attach current MAR sheet : Please list any other herbal/homeopathic preparations not on MAR sheet: New medicines: New medicines: New medicines: New medicines: Date of last medication review: Can the resident swallow their medications? If no, how is this managed? Details: Details: Details: Details: Is the resident on oxygen? If yes, at what level of oxygen therapy? Observations (baseline) Reading: Date: Signature: Date / Sign: Date / Sign Date / Sign Date / Sign Oxygen Saturation Heart Rate Blood Pressure: Sitting Blood Pressure: Standing Respiratory Rate Temperature Blood Sugar (if indicated) Urine Height Weight Page 4 of 10
5 BASELINE: SKIN INTEGRITY REVIEW: SKIN INTEGRITY Skin integrity Waterlow: Is skin intact Prone to bruising Has there been any deterioration in skin condition? Details: Existing pressure areas reported Are there any wounds Details: Details of any dressings: Page 5 of 10
6 BASELINE: NUTRITION REVIEW: NUTRITION BASELINE: FUNCTION REVIEW: FUNCTION Baseline function Number of falls in the last 12 months: Reason for falls: Details: Details: Details: Details: Is the person on more than four medicines? Is the person at risk of falls? If yes, please complete falls risk assessment Current mobility, including any walking aids if required and approximate distance: Stairs: Current transfers, including any equipment if needed: Bed Chair Toilet Nutrition Any unintentional weight loss? Details: Any swallowing problems: Page 6 of 10
7 BASELINE: INFECTION CONTROL REVIEW: INFECTION CONTROL BASELINE: CONTINENCE REVIEW: CONTINENCE BASELINE: NUTRITION REVIEW: NUTRITION Details: What is their MUST score? Mealtime information e.g. Can they feed themselves, are they slow to eat, on supplements Comments: Continence Faecal Constipation incontinence Please tick: Urinary Catheter incontinence Does the person have supply of continence products? Reason/indication for long term indwelling urinary catheter: Stoma Size: Date of last assessment for ongoing need: Date catheter was last change: Infection Prevention and Control Is the person an infection risk? If yes, please list (ie: MRSA, C.Diff, TB) Change Change: Change: Change: Please give details of results and treatment: Page 7 of 10
8 BASELINE: END OF LIFE CARE REVIEW: END OF LIFE CARE End of Life Care Is the person known to St Raphael s palliative care team? CNS name: Is there an Advance Care Plan? Review date: Is there a DNACPR form? Preferred place of care at end of life: If yes, please specify: Details: Details: Details: Details: Preferred place of death: If yes, please specify: Details: Details: Details: Details: Is there a Coordinate my Care record? Has consent for CMC been obtained? Has pain been assessed using a pain assessment tool? Comments/ actions: Page 8 of 10
9 BASELINE: REFERRALS REVIEW: REFERRALS Is a referral required (please tick as appropriate): Supportive Care home team Date of referral & assessment Date of referral & assessment Date of referral & assessment Date of referral & assessment Hospice at Home Challenging Behaviour team Pain team Pharmacist (if on 4 or more meds or problems swallowing meds) Falls service Physio Airways Heart failure Tissue Viability Continence Service District nurse Speech and Language Therapy Dietician Respiratory team Psychiatry Continuing care for CHC consideration Please list other services: Page 9 of 10
10 BASELINE REVIEW Baseline information completed by: Review information completed by: Signature: Qualification: Date and time: Consent - I consent to personal information for active administration of my hospital discharge to be shared with my care home. Signature: Date: Please note if the resident does not have capacity, the consent needs to be signed by the lasting power of attorney or the registered GP. Page 10 of 10
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