Health Practitioner Physical Assessment Form PDF Details

The Health Practitioner Physical Assessment form is a comprehensive document designed for use by various healthcare professionals including primary physicians, certified nurse practitioners, registered nurses, certified nurse-midwives, and physician assistants. This form plays a critical role in the initial assessment of individuals seeking admission into assisted living programs within Maryland, detailing explicit regulations that limit the provision of services based on the care level required by the resident at the time of admission. It encompasses sections aimed at capturing the current medical and psychiatric history, chronic conditions, allergies, risk of communicable diseases, substance abuse history, risk factors for falls and injury, skin conditions, sensory impairments, nutritional status, and cognitive or behavioral status. Specifically, it highlights triggers for awake overnight staff, emphasizing conditions that necessitate more vigilant observation and care. Furthermore, it assesses the resident’s ability to self-administer medication and make health-care decisions, ensuring a multifaceted evaluation of their physical and cognitive capabilities. Certain questions are marked with an asterisk to denote these triggers, underscoring the necessity for detailed and attentive completion of the form to meet regulatory standards and secure the well-being of assisted living residents. The document also outlines procedures for medication and treatment orders, accentuating the importance of a thorough and accurate health assessment in planning and delivering personalized care. This form serves not only as a tool for evaluating the suitability of a resident for assisted living care but also plays a vital role in the ongoing management of their health and wellness.

QuestionAnswer
Form NameHealth Practitioner Physical Assessment Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesform care practitioner assessment, nurse practitioner patient physical and yealth assessment form, health care practitioner physical assessment form, care practitioner physical assessment form

Form Preview Example

1

Resident Name __________________________________

Date Completed ______________________

Date of Birth ____________________________________

 

Health Care Practitioner Physical Assessment Form

This form is to be completed by a primary physician, certified nurse practitioner, registered nurse, certified nurse- midwife or physician assistant. Questions noted with an asterisk are “triggers” for awake overnight staff.

Please note the following before filling out this form: Under Maryland regulations an assisted living program may not provide services to a resident who, at the time of initial admission, as established by the initial assessment, requires: (1) More than intermittent nursing care; (2) Treatment of stage three or stage four skin ulcers; (3) Ventilator services; (4) Skilled monitoring, testing, and aggressive adjustment of medications and treatments where there is the presence of, or risk for, a fluctuating acute condition; (5) Monitoring of a chronic medical condition that is not controllable through readily available medications and treatments; or (6) Treatment for a disease or condition that requires more than contact isolation. An exception to the conditions listed above is provided for residents who are under the care of a licensed general hospice program.

1.* Current Medical and Psychiatric History. Briefly describe recent changes in health or behavioral status, suicide attempts, hospitalizations, falls, etc., within the past 6 months.

2.* Briefly describe any past illnesses or chronic conditions (including hospitalizations), past suicide attempts, physical, functional, and psychological condition changes over the years.

3.Allergies. List any allergies or sensitivities to food, medications, or environmental factors, and if known, the nature of the problem (e.g., rash, anaphylactic reaction, GI symptom, etc.). Please enter medication allergies here and also in Item 12 for medication allergies.

4.Communicable Diseases. Is the resident free from communicable TB and any other active reportable airborne communicable disease(s)?

(Check one)

Yes

No If “No,” then indicate the communicable disease: ________________________

Which tests were done to verify the resident is free from active TB?

 

PPD

 

 

Date: __________

Result:___________mm

Chest X-Ray (if PPD positive or unable to administer a PPD)

Date: __________

Result_____________

Form 4506 Revised 9-15-09

2

Resident Name __________________________________

Date Completed ______________________

Date of Birth ____________________________________

 

5.History. Does the resident have a history or current problem related to abuse of prescription, non-prescription, over-the-counter (OTC), illegal drugs, alcohol, inhalants, etc.?

(a)Substance: OTC, non-prescription medication abuse or misuse

1.

Recent (within the last 6 months)

Yes

No

2.

History

Yes

No

(b)Abuse or misuse of prescription medication or herbal supplements

1.

Currently

Yes

No

2.

Recent (within the last 6 months)

Yes

No

(c)History of non-compliance with prescribed medication

1.

Currently

Yes

No

2.

Recent (within the last 6 months)

Yes

No

(d)Describe misuse or abuse: _________________________________________________________

____________________________________________________________________________________

6.* Risk factors for falls and injury. Identify any conditions about this resident that increase his/her risk of falling or

injury (check all that apply): orthostatic hypotension osteoporosis gait problem impaired

balance confusion Parkinsonism foot deformity pain assistive devices other (explain)

__________________________________________________________________________________________

 

7.* Skin condition(s). Identify any history of or current ulcers, rashes, or skin tears with any standing treatment

 

orders. _________________________________________________________________________________

 

__________________________________________________________________________________________

 

8.* Sensory impairments affecting functioning. (Check all that apply.)

 

 

 

 

 

 

 

(a) Hearing:

Left ear:

 

 

 

Adequate

 

Poor

Deaf

 

Uses corrective aid

 

 

 

(b) Vision:

Right ear:

 

 

 

Adequate

 

Poor

Deaf

 

Uses corrective aid

 

 

 

Adequate

Poor

 

Uses corrective lenses

Blind (check all that apply) -

R

L

(c) Temperature Sensitivity:

 

 

 

Normal

Decreased sensation to:

Heat

Cold

 

 

 

9. Current Nutritional Status.

Height

 

 

inches

 

 

Weight

 

lbs.

 

 

 

 

 

(a) Any weight change (gain or loss)

in the

past 6 months?

 

 

 

 

 

Yes

No

 

 

(b) How much weight change?

 

 

lbs. in the past

 

months (check one)

Gain

Loss

 

 

(c) Monitoring necessary? (Check one.)

 

 

 

 

 

 

 

Yes

No

 

 

If items (a), (b), or (c) are checked, explain how and at what frequency monitoring is to occur: ___________

 

__________________________________________________________________________________________

 

(d) Is there evidence of malnutrition or risk for undernutrition?

 

 

 

Yes

No

 

 

(e)* Is there evidence of dehydration or a risk for dehydration?

 

 

 

Yes

No

 

 

(f) Monitoring of nutrition or hydration status necessary?

 

 

 

 

 

Yes

No

 

 

If items (d) or (e) are checked, explain how and at what frequency monitoring is to occur: _______________

__________________________________________________________________________________________

(g)Does the resident have medical or dental conditions affecting: (Check all that apply)

Chewing Swallowing Eating Pocketing food Tube feeding

(h)Note any special therapeutic diet (e.g., sodium restricted, renal, calorie, or no concentrated sweets restricted): _________________________________________________________________________________

__________________________________________________________________________________________

(i)Modified consistency (e.g., pureed, mechanical soft, or thickened liquids): _________________________

__________________________________________________________________________________________

(j) Is there a need for assistive devices with eating (If yes, check all that apply):

Yes

No

Weighted spoon or built up fork

Plate guard

Special cup/glass

 

 

(k) Monitoring necessary? (Check one.)

 

 

Yes

No

If items (g), (h), or (i) are checked, please explain how and at what frequency monitoring is to occur:

__________________________________________________________________________________________

Form 4506 Revised 9-15-09

Alzheimer’s Disease Multi-infarct/Vascular Parkinson’s Disease
Date ______________ Score ______________

3

Resident Name __________________________________

Date Completed ______________________

Date of Birth ____________________________________

 

10.* Cognitive/Behavioral Status.

(a)* Is there evidence of dementia? (Check one.)

(b) Has the resident undergone an evaluation for dementia? (c)* Diagnosis (cause(s) of dementia):

(d)Mini-Mental Status Exam (if tested)

Yes

No

Yes

No

Other

10(e)* Instructions for the following items: For each item, circle the appropriate level of frequency or intensity, depending on the item. Use the “Comments” column to provide any relevant details.

Item 10(e)

A

B*

C*

 

D*

Comments

 

 

 

Cognition

 

 

 

I. Disorientation

Never

Occasional

Regular

 

Continuous

 

II. Impaired recall

Never

Occasional

Regular

 

Continuous

 

(recent/distant events)

 

 

 

 

 

 

 

 

III. Impaired judgment

Never

Occasional

Regular

 

Continuous

 

IV. Hallucinations

Never

Occasional

Regular

 

Continuous

 

 

 

 

 

 

 

 

V. Delusions

Never

Occasional

Regular

 

Continuous

 

 

 

 

Communication

 

 

 

VI. Receptive/expressive

Never

Occasional

Regular

 

Continuous

 

aphasia

 

 

 

 

 

 

 

 

 

 

Mood

and Emotions

 

 

VII. Anxiety

Never

Occasional

Regular

 

Continuous

 

 

 

 

 

 

 

 

VIII. Depression

Never

Occasional

Regular

 

Continuous

 

 

 

 

Behaviors

 

 

 

IX. Unsafe behaviors

Never

Occasional

Regular

 

Continuous

 

 

 

 

 

 

 

 

X. Dangerous to self or

Never

Occasional

Regular

 

Continuous

 

others

 

 

 

 

 

 

 

 

XI. Agitation (Describe

 

 

 

 

 

 

behaviors in comments

Never

Occasional

Regular

 

Continuous

 

section)

 

 

 

 

 

 

10(f) Health care decision-making capacity. Based on the preceding review of functional capabilities, physical and cognitive status, and limitations, indicate this resident’s highest level of ability to make health care decisions.

(a) Probably can make higher level decisions (such as whether to undergo or withdraw life-sustaining treatments that require understanding the nature, probable consequences, burdens, and risks of proposed treatment).

(b) Probably can make limited decisions that require simple understanding.

(c) Probably can express agreement with decisions proposed by someone else.

(d) Cannot effectively participate in any kind of health care decision-making.

11.* Ability to self-administer medications. Based on the preceding review of functional capabilities, physical and cognitive status, and limitations, rate this resident’s ability to take his/her own medications safely and appropriately.

(a) Independently without assistance

(b) Can do so with physical assistance, reminders, or supervision only

(c) Need to have medications administered by someone else

___________________________________

________________

Print Name

Date

______________________________________

 

Signature of Health Care Practitioner

 

Form 4506 Revised 9-15-09

4

Resident Name __________________________________

Date Completed ______________________

Date of Birth ____________________________________

 

PRESCRIBER’S MEDICATION AND TREATMENT ORDERS AND OTHER INFORMATION

Allergies (list all): ___________________________________________________________________________________________________________________

Note: Does resident require medications crushed or in liquid form? Indicate in 12(a) with medication order. If medication is not to be crushed please indicate.

12(a) Medication(s). Including PRN, OTC, herbal, & dietary supplements.

Include dosage route (p.o., etc.), frequency, duration (if limited).

12(b) All related diagnoses, problems, conditions.

Please include all diagnoses that are currently being treated by this medication.

12(c) Treatments (include frequency & any instructions about when to notify the physician).

Please link diagnosis, condition or problem as noted in prior sections.

12(d) Related testing or monitoring.

Include frequency & any instructions to notify physician.

Prescriber’s Signature ________________________________________________________

Date

______________________________

Office Address ______________________________________________________________

Phone

______________________________

Form 4506 Revised 9-15-09

5

Resident Name __________________________________

Date Completed ______________________

Date of Birth ____________________________________

 

PRESCRIBER’S MEDICATION AND TREATMENT ORDERS AND OTHER INFORMATION

Allergies (list all): ___________________________________________________________________________________________________________________

Note: Does resident require medications crushed or in liquid form? Indicate in 12(a) with medication order. If medication is not to be crushed please indicate.

12(a) Medication(s). Including PRN, OTC, herbal, & dietary supplements.

Include dosage route (p.o., etc.), frequency, duration (if limited).

12(b) All related diagnoses, problems, conditions.

Please include all diagnoses that are currently being treated by this medication.

12(c) Treatments (include frequency & any instructions about when to notify the physician).

Please link diagnosis, condition or problem as noted in prior sections.

12(d) Related testing or monitoring.

Include frequency & any instructions to notify physician.

Prescriber’s Signature ________________________________________________________

Date

______________________________

Office Address ______________________________________________________________

Phone

______________________________

Form 4506 Revised 9-15-09

How to Edit Health Practitioner Physical Assessment Form Online for Free

Number of tasks can be quicker than managing files taking advantage of the PDF editor. There isn't much for you to do to enhance the nurse practitioner patient physical and yealth assessment form form - just simply follow these steps in the next order:

Step 1: Hit the orange button "Get Form Here" on this web page.

Step 2: At this point, you're on the document editing page. You may add information, edit current information, highlight certain words or phrases, insert crosses or checks, insert images, sign the document, erase unnecessary fields, etc.

Create the nurse practitioner patient physical and yealth assessment form PDF by typing in the data meant for each part.

writing care practitioner physical assessment form part 1

Type in the necessary information in the physical functional and, Allergies List any allergies or, nature of the problem eg rash, Communicable Diseases Is the, communicable diseases, Check one, Yes, No If No then indicate the, Which tests were done to verify, and Date Resultmm segment.

care practitioner physical assessment form physical functional and, Allergies List any allergies or, nature of the problem eg rash, Communicable Diseases Is the, communicable diseases, Check one, Yes, No If No then indicate the, Which tests were done to verify, and Date Resultmm fields to fill out

In the Resident Name, Date Completed, Date of Birth, History Does the resident have a, overthecounter OTC illegal drugs, a Substance OTC nonprescription, Recent within the last months, Yes Yes, No No, b Abuse or misuse of prescription, Currently Recent within the last, Yes Yes c History of noncompliance, Currently Recent within the last, No No, and No No segment, emphasize the essential details.

Filling in care practitioner physical assessment form part 3

The Sensory impairments affecting, Left ear Right ear, Adequate Adequate, Poor Poor, Deaf Uses corrective aid Deaf Uses, b Vision c Temperature Sensitivity, Adequate, Poor, Uses corrective lenses, Blind check all that apply, Normal, Decreased sensation to, Heat, Cold, and Weight lbs area is the place where both sides can indicate their rights and responsibilities.

care practitioner physical assessment form Sensory impairments affecting, Left ear Right ear, Adequate Adequate, Poor Poor, Deaf Uses corrective aid Deaf Uses, b Vision c Temperature Sensitivity, Adequate, Poor, Uses corrective lenses, Blind check all that apply, Normal, Decreased sensation to, Heat, Cold, and Weight lbs blanks to fill out

Prepare the document by looking at all these sections: h Note any special therapeutic, Yes, Weighted spoon or built up fork, Plate guard, Special cupglass, k Monitoring necessary Check one, Yes, and Form Revised.

Completing care practitioner physical assessment form step 5

Step 3: Press "Done". Now you may transfer the PDF document.

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