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					Comprehensive Interdisciplinary Patient Assessment - MONTHLY/UNSTABLE                                                                    Page 1 of 11
Patient Name/Label: _______________________________________________________Admission Date: _____________________
Section 1                                     Demographics
Section 1A
Date of Birth: ____________________             Gender:       Male      Female        Transgender/Transsexual
Marital Status:  Single       Married        Widow        Divorced   Separated      Unknown
Race/Ethnicity:  American Indian/Alaska Native       Asian _____________      Black /African American Hispanic/Latino origin
                 Native Hawaiian or Pacific Islander       White     Unknown
Nephrologist :________________________________________ Vascular Surgeon:_____________________________ Unknown
Family Physician:______________________________                       Unknown General Surgeon:_____________________________                      Unknown
Mental Health Provider: _____________________________                 Unknown Dentist:_____________________________________                      Unknown
First Dialysis Date: ________________________ (located on 2728)                First Date of Treatment at facility: __________________________


Section 1B
Patient's condition is currently:
   Initial Date:___________         Monthly/Unstable Date:____________             90 Days Date:_____________            Annual/Stable Date:__________

Patient is unstable if he/she has any of the following:
    ”Frequent Hospitalization” more than three hospitalizations in one month or “Extended Hospitalization” longer than 8 days / new substantial
change in condition resulting in significant changes in medical or functional status (Stroke, additional co-morbid diagnoses, amputations requiring rehab.)
    ”Poor nutritional status” include failure to thrive symptoms, with loss of body weight and low serum albumin
    ”Unmanaged anemia” would include continued lab findings of Hgb/Hct which are out of range 10-12 g/dL, <13.0 g/dL.
Ferritin >100 mg/mL <500 mg/mL., Transferrin saturation >20%
    ”Significant change in psychosocial needs” May include instability in one’s own or immediate family member’s employment, physical or
emotional abuse, deterioration in mental or functional status, housing instability, death or major illness in the family, and loss of emotional support
    ”Inadequate dialysis” Include findings of Kt/V or URR which do not meet minimum expectations. Kt/V ≥ 1.2 or URR ≥ 65%
    New substantial change in condition that is a recurrent serious complication while undergoing dialysis
( severe hypotension, seizures, dysrhythmia, blood access issues resulting in freq. interventions/changes to dialysis orders to achieve adequate dialysis )
    Refer to plan of care                       Per judgment of the team                        Per request of the patient
    Other____________________________________________________________________________________________________________


Section 1C        N/A
Current HD Orders:             Refer to Facility MD order sheet       See attached Facility MD order sheet
Patients on Hemodialysis:         N/A     Dialysate: K:_________Ca++_________Bicarb________Na:________Temp________EDW:__________
Adequacy meeting target:: Yes             No, Explain________________________________________ Refer to plan of care
Adverse Intradialytic Symptoms:           Cramping    Hypertension  Dizziness  Hypotension   Nausea     Cardiovascular complication

Section 1D      N/A
Patients on Peritoneal Dialysis:   N/A          CCPD       CAPD Total daily Volume:_________________________Kt/V___________________
 PET results Low         Low average            High average   High        Usual Dextrose: Icodextran    Which exchange_____________


Section 1E
Admission Labs:            Refer to attach lab results
Comprehensive Interdisciplinary Patient Assessment - MONTHLY/UNSTABLE                                                                 Page 2 of 11
Patient Name/Label: _______________________________________________________Admission Date: _____________________
SECTION 3                                        NURSING HISTORY
SECTION 3B      N/A
General Health Status:         Good        Fair       Poor
Current Vital Signs: Height _________ Weight _________                 Well nourished      Obese      Thin
B/P Standing __________         Unable to stand           B/P Sitting ________        Apical Pulse __________ Heart Rhythm:       Regular    ]Irregular
Resp: ________         Cough       SOB              Temp: ____________
   Near total / Total Disability Cannot work, difficulty participating socially. Barely able to perform self-care.
   Frequent hospitalization for management of complications and physical symptoms.
   Marked Disability Substantially reduced work load and participation in social activities. Some independence in self care
   Mild/Moderate disability Performs all or most ADL’s. Moderate limitations from symptoms or lack of endurance
   Minimal /No disability Performs all or most ADL’s without limitation. Some adjustment in social activities        Refer to plan of care


SECTION 3C N/A
Blood Pressure Control (K/DOQI C-Level Goal: <140/80 post dialysis sitting)
Average/Typical _________________                 Stable Blood Pressure / No action
Frequently has Intradialytic:    Hypertension ____________            Hypotension _______________
Action:     Refer to plan of care      Monitor Monthly            Education regarding anti-hypertensive therapy compliance
             Adjust EDW weight as needed             Adjust blood pressure medication
   Other:_________________________________________________________________________________________________________


SECTION 3D N/A
Frequent Hospitalizations:            No           Yes, Action:     Educate patient / family regarding ESRD & complications
   Refer for permanent access placement or revision               Reinforce prescribed treatment/medications/fluid/diet    Refer to plan of care
Other:_____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Comprehensive Interdisciplinary Patient Assessment - MONTHLY/UNSTABLE                                                              Page 3 of 11
Patient Name/Label: _______________________________________________________Admission Date: _____________________
SECTION 3 - PART A                              NURSING HISTORY
SECTION 3 - PART A1 N/A
Access Status: Current Access: AVF Type: Simple Fistula Transposed vein             AVG Type: Poly      Vectra     Other_________
Average Arterial Pressure:____________ Average Venous Pressure:______________ Cannulation Method: Rotation     Button Hole
Physical description of access:    Straight   Curved     Lop tortuous  Aneurysms Direction of Flow:___________________________
  CVC – Location:________Date Placed:______________ Average Arterial Pressure:_________ Average Venous Pressure:____________
  Maturing permanent access Works well   Difficult cannulation Intermittent flow issues High Ven. Pressures Low Art. Pressures
SECTION 3 – PART A3
Anticoagulation:        N/A Heparin bolus dose:_____________ Maintenance dose:_____________ Other:__________________________

SECTION 3 – PART A4      N/A
Access Surveillance Method: Physical Findings:        Persistent swelling     Collateral veins      prolonged bleeding    Altered bruit / thrill
    Intra-access flow – Method_________________          Static pressure – Method______________ Duplex ultrasound     Recirculation
Interventions Required: No       Yes      Angioplasty              Date:____________________ Where____________________________
                                          Surgical Revision        Date:____________________ Where____________________________
                                          Procedures Declotting Date:____________________ Where____________________________
SECTION 3 – PARTA5 N/A
Central Venous Catheter: Type of CVC: Quinton          Arrow       Other:__________ Temporary Catheter: Quinton   Other:__________
Catheter Dysfunction: Manipulation or replacement – Date:__________________________Where:___________________________________
Thrombolytic agent: Alteplase        Other:______________ Frequency:_______________           Reversed Lines
SECTION 3 – PART A6     N/A    Hemodialysis Access History of infection: No       Yes
  Staph aureus   Staph aureus methicillin resistant (MRSA) Staph epi   Staph epi methicillin resistant                E-Coli     Pseudomonas
  Enterococcus      Enterococcus vancomycin resistant (VRE)          Fungus        Other_____________________________________________
Treatment:    Vancomycin        Cefazolin      Gentamycin       Azactam       Zinzolid       Other_______________________________________
SECTION 3 – PART A7         N/A Access Action:       Refer to surgeon for permanent access placement         Patient/Family education on access care
  Not a candidate for permanent access placement Refer to Indications for Hemodialysis Catheter Use below           Patient preference
  All sites exhausted      Limiting co-morbid conditions    Refer to surgeon for follow up       Routine monitoring of access
  Other__________________________________________________________________________________________________________
SECTION 3 – PART A8          N/A Indications for Hemodialysis Catheter Use:
   New patient awaiting placement of fistula/graft. (Scheduled date for permanent access placement _____/_____/_____)
   New patient awaiting maturation/healing of fistula or graft. (Date access placed _____/_____/_____)
   Established patient with failed fistula/graft  new fistula/graft planned. (Scheduled date for access placement_____/_____/_____)
   Established patient with failed fistula/graft  awaiting maturation/healing of new access. (Date access placed_____/_____/_____)
   Unable to tolerate increased cardiac output induced by a fistula/graft due to cardiac
                    Condition. (i.e. severe coronary artery disease) or congestive heart failure.
   Severe peripheral vascular disease precludes fistula/graft placement.
   All possible graft/fistula access sites exhausted and unable to do peritoneal dialysis.
   Awaiting a living donor transplant. (If an extended pre-transplant waiting period is
                    Anticipated, placement of a permanent access should be considered).
   Peritoneal dialysis patient requiring a short-term course of Hemodialysis therapy. Date of planned return to peritoneal dialysis ____/____/____)
   Severe vasculitis precludes graft/fistula placement or use until (if) condition improves.
   Dermatologic condition involving extremities precludes graft/fistula placement or use (i.e.scleroderma, calciphylaxis, etc.)
   Patient refusing permanent access.
   Other: Illegal patients – have no coverage_____________________________________
Comprehensive Interdisciplinary Patient Assessment - MONTHLY/UNSTABLE                                                              Page 4 of 11
Patient Name/Label: _______________________________________________________Admission Date: _____________________
SECTION 3 – PART B        N/A                      NURSING HISTORY
SECTION 3 – PART B1
Peritoneal Dialysis Catheter: Type of catheter: Straight    Coiled      Swan neck      Cruz   Other:_____________________________
Insertion Date:________________________________________________________Surgeon:_____________________________ Unknown
Exit site care: Soap and water        Other:_____________ Antibiotic Ointment: Type:____________________ Exit Site Width:____________
Recent Trauma: No        Yes, Explain___________________________________________________________________________________
Catheter Function: Patent           Migration     Repositioned        Replaced: Type:___________________ Date:___________________
Thrombolytic agent: Alteplase         Heparin      Other:____________ Dose:___________________ Frequency::__________________
SECTION 3 – PART B2       N/A
Peritoneal Dialysis Access History of infection:      No    Yes
   Staph aureus     Staph aureus methicillin resistant (MRSA)     Staph epi       Staph epi methicillin resistant      E-Coli      Pseudomonas
   Enterococcus     Enterococcus vancomycin resistant (VRE)         Fungus        Other_____________________________________________
Treatment:    Vancomycin      Cefazolin      Gentamycin         Azactam       Zinzolid     Other_______________________________________
SECTION 3 – PART C                                          NURSING HISTORY
SECTION 3 – PART C1 N/A
Current Medication / Therapy List
Medication Review (Goal: Medication taken as prescribed)   Follows prescriptions?            Yes       No
Do you have problems related to the medications you take? No          Yes, Explain_____________________________________________
Do you have another physician prescribing medications? No           Yes, Name:_________________________________________________
Medications:________________________________________________________________________________________________________
Medications:________________________________________________________________________________________________________
Medications:________________________________________________________________________________________________________
Pharmacy name:____________________________________phone:______________________________                              Unknown
Action:   Patient/family education provided on medication schedule, purpose and side effects
Other:____________________________________________________________________________________________________________


SECTION 3 – PART C2       N/A
Current Medication / Therapy List
Aranesp__________mcg Vial SQ/IV Q week          N/A             EPO _____________units/IV/SQ           2Xweek        3X week       N/A
Hectorol _________mcg IV or PO TIW        N/A                   Zemplar _________mcg IV TIW           N/A       Rocaltrol_____mcg PO TIW           N/A
Ferrlicet __________mg / IV    X 8 Tx     Q week       Q Month        Venofer _____________mg / IV           X 8 Tx       Q week         Q Month
Phosphorous Binders     Phoslo _____________       Renagel ____________         Fosrenol _______________            Tums___________________
          Hypertensive medication                           OTC Medications                                   Other Medication
_______________________________                 _______________________________                    ______________________________
_______________________________                 _______________________________                    ______________________________
_______________________________                 _______________________________                    ______________________________
_______________________________                 _______________________________                    ______________________________
_______________________________                 _______________________________                    ______________________________
_______________________________                 _______________________________                    ______________________________
_______________________________                 _______________________________                    ______________________________
_______________________________                 _______________________________                    ______________________________
_______________________________                 _______________________________                    ______________________________
_______________________________                 _______________________________                    ______________________________
Comprehensive Interdisciplinary Patient Assessment - MONTHLY/UNSTABLE                                                              Page 5 of 11
Patient Name/Label: _______________________________________________________Admission Date: _____________________
SECTION 3 – PART D                      NURSING PHYSICAL ASSESSMENT
Infection:       N/A             No Problems         MRSA        VRE       Active (current) Explanation: ____________________________________
     Chronic Hep B          Chronic Hep C          Active (current) Explanation: _________________________________________________________
Other:______________________________________________________________________________________________________________

Surgical Procedures :            N/A      No Problems            Transplant          Transplant Nephrectomy                CABG
[ ] Other__________________________________________________________________________________________________________
SECTION 3 – PART E               N/A                                   PAIN ASSESSMENT
Pain Assessment Rate the pain by circling the number                              Right   Front      Left                Left    Back     Right
 Number that best describes your pain on the AVERAGE?
 I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I
 0        1      2      3         4      5     6        7    8     9     10
No Pain   I   MILD PAIN_I    I MODERATE PAIN I I __SEVERE PAIN_ I
Number that best describes your pain at its LEAST in the past week?
 I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I
 0        1      2      3         4      5     6        7    8     9     10
No Pain   I   MILD PAIN_I    I MODERATE PAIN I I __SEVERE PAIN_ I
Number that best describes your pain at its WORST in the past week?
 I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I_ I
 0        1      2      3         4      5     6        7    8     9     10
No Pain   I   MILD PAIN_I    I MODERATE PAIN I I __SEVERE PAIN_ I
What kinds of things make your pain feel better? (Heat, Meds, rest)
                                                                                           On the diagram, mark an X over area of pain
_____________________________________________
                                                                              In the last week, how much relief have pain treatment or medications
What kinds of things make your pain worse? (Walking, Standing, Lifting)       provided? Please circle the one percentage that most show how much
_____________________________________________                                 relief you have received.
What treatments or medications are you receiving for pain?                      I_ __ I_ _ I_ _ I_ _ I_ _ I_ _ I_ _ I_ _ I_ _ I_ _ I
_____________________________________________                                  0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
                                                                              No                                      Complete
Refer to pain clinic:       No         Yes, _________________________         Relief                                  Relief

SECTION 3 – PART F              N/A                           FALL RISK ASSESSMENT
SECTION 3 – PART F4
Fall Risk Assessment Required core elements: Asses one point for each care element “yes”                                                  Yes     No
Diagnosis (3 or more co-existing) Assess for hypotension,
Prior history of falls within 3 months Fall definition, “An unintentional change in position resulting in coming to rest on the ground.
Incontinence Inability to make it to the bathroom or commode in timely manner. Includes frequency, urgency, and /or nocturia.
Visual impairment Includes macular degeneration, diabetic retinopathies, visual field loss, related changes, decline in visual acuity,
accommodation, glare tolerance, depth perception, and night vision or not wearing prescribed glasses or having the correct
prescription.
Environmental hazards May include poor illumination, equipment tubing, inappropriate footwear, pets, hard to reach items, floor
surfaces that are uneven or cluttered, or outdoor entry and exits.
Poly Pharmacy (4 or more prescriptions) Drugs highly associated with fall risk include but not limited to, sedatives, anti-
depressants, tranquilizers, narcotics, antihypertensive, cardiac meds, corticosteroids, anti-anxiety drugs, anticholinergic drugs, and
hypoglycemic drugs.
Pain affecting level of function Pain often affects an individual’s desire or ability to move or pain can be a factor in depression or
compliance with safety recommendations.
Cognitive impairment Could include patients with dementia, Alzheimer’s or stroke patients or patients who are confused, use poor
judgment have decreased comprehension, impulsivity, memory deficits. Consider patients ability to adhere to the plan of care.
                                              A score of “YES” 4 or more is considered at risk for falling             Total
Comprehensive Interdisciplinary Patient Assessment - MONTHLY/UNSTABLE                                                           Page 6 of 11
Patient Name/Label: _______________________________________________________Admission Date: _____________________
SECTION 3 - PART G         N/A                DIALYSIS ADEQUACY
Medical Management:         Adequacy of Dialysis     Goal: URR > 68%, Kt/v >1.4               URR: _____ Kt/V_____
Action: Monitor monthly URR      Educate patient on his/her role in achieving adequate dialysis Evaluate Access          Schedule fistula gram
Treatment duration Δ:    Increase______       Decrease_____ Dialyzer size Δ: Increase______              Decrease_____       Refer to plan of care
Missed treatment % in the last 30 days? (Disregard treatments missed due to hospitalization/travel/or another setting: Percentage:___________
    Other:_____________________________________________________________________________________________________________


SECTION 3 - PART H                  N/A                     ANEMIA MANAGEMENT
Anemia Management: Goal: Hgb 11-12 mg/dl, Tsat > 20% Ferritin >100 <500 Hgb : ______ Hct:______ Tsat : ______ Ferritin;_______
                           Is Hgb 11-12?     Yes       No     Is Ferritin >100 <500      Yes      No        Is Tsat > 20%       Yes No
Is there an active infection?     Yes     No Organism:_______________________________
Is co-morbid conditions affecting anemia:     Yes      No If yes, what?
__________________________________________________________
Recent transfusions:         Yes      No          Predisposition to bleeding?      Yes       No
Rapid change in Hgb          Yes      No         Occult blood tested? Yes           No If yes, date & results:_____________________________
ESA dose:_________________________________ Date of last ESA Change ___________________________________________________
Iron dose:__________________________________ Date of last iron dose change:_______________________________________________
Other:_____________________________________________________________________________________________________________
Action: Monitor Hgb and Tsat per protocol and/or Monthly                    Adjust ESA per MD order/protocol Monthly
           Administer/adjust IV iron per MD Order/Protocol                  Evaluate for causes of hypo response to ESA
           Current Prescribed ESA treatment:_________                       Draw Carnitor level            Refer to plan of care


SECTION 3 - PART I             N/A                      BONE MANAGEMENT
Bone Management Goal: Intact PTH 150-300, Ca: 8.5-10.2, PO4: 3-5.5, Ca x PO4 product: 55               Refer to attached lab results
Lab Review: Ca : _____ cCa : ____ Ca x PO4: _______ cCa x PO4: _______ PO4:__________ Intact PTH: ______
Phosphorus:_____________________ Trends: Usually in Goal                  Usually High       Usually Low        Other_____________________
Calcium:_________________________ Trends: Usually in Goal                  Usually High      Usually Low        Other_____________________
Intact PTH:_______________________ Trends: Usually in Goal                 Usually High      Usually Low        Other_____________________
Medications: Phosphorus binder__________________________ Calcium supplement__________________________________________
    Vitamin D ___________________________________________ Diet Issues: Adherence Good                     Fair        Poor
Education: Understands diet: Yes         No Comments:___________________________________________________________________
Action: Refer to plan of care      Monitor pertinent chemistries per protocol and/or Monthly             Follow vitamin D protocol
    Educate patient on bone health               Phosphorus counseling on diet and taking binders as prescribed/adjust binder dose
    Current Prescribed Vitamin D analog:____________________________________________________________________________________
Comprehensive Interdisciplinary Patient Assessment - MONTHLY/UNSTABLE                                                      Page 7 of 11
Patient Name/Label: _______________________________________________________Admission Date: _____________________
SECTION 4                                     DIETITIAN ASSESSMENT
SECTION 4A        N/A
Nutritional Status; Goal: Albumin => 3.5      Albumin: ______________
Diet Order: _________________________________________ Weight Change?          Yes       No If “Yes” - % wt. change _______
Medical History:_______________________________________________________________________________________________________
SECTION 4B         N/A
Treatment: Hemodialysis _______times/week PD Dialysate Rx         1.5% 2.5% 4.25%               Fill______________
HT_____ In/______cm WT______#/______kg IBM________±10% WT Hx ____________BMI ______Age ______Sex_______
EDW__________________________IDWG (Intradialytic Wt gain)_________ kg
SECTION 4C          N/A
Medications Changes: EPO __________           Hectoral _________      Venofer/Ferrlicet ____________       Carnitine _______________
   Phosphorus binders _______________________ Sensipar          Potassium bath to ________K+       Vitamins______________________
SECTION 4D        N/A Laboratory Values: Date:__________________________ MD aware                          √Carnitine Level___________
Ca++___________ URR___________ Albumin________ iPTH___________ PO4_______ BUN_______________
Glucose_________ HCT___________ HGB___________ Hgb A1C ________ K+ ________ Creatinine________ Cholesterol__________
WBC________        Tsat_______% Ferritin__________ HGBx3_________ Ca/Phos Product_____________ Triglycerides ____________
Diabetes Mellitus controlled Yes No N/A Bone Disease controlled Yes No N/A Anemia controlled Yes No N/A
SECTION 4F        N/A                                   Estimated Nutritional needs:
Caloric Needs _______cal/kg EDW Protein Needs _____________gm/kg IBW Fluid Needs _____________ml/kg BW
Oral Intake:__________% Consumed Urine output _______mL/day Leaves > 25% of food uneaten at most meals Maintains fluid restriction
____________________TF Formula Provides ____________________Total ml/day (24 hours) __________________gm protein
____________________ml total water                  ____________________%RDI                     __________________ml free water
____________________ml flush                        ____________________Added water              ___________________cal/kg bw/day
Total calories (%) from Parenteral or tube feeding:     None       1%-25%          26%-50%      51%-75%       75%-100%
Average fluid intake by tube or IV: 1-500cc/day           501-1000cc/day         1001-1500cc/day    1501-2000cc/day      2001cc/day
SECTION 4G          N/A
Skin Status Clinical Observations: Muscle wasting Areas _______________________________Severity______________________________
Edema Areas__________________________________________________________________ +1                       +2      +3    +4
Subcutaneous Fat Depletion: Areas_______________________________________________Severity_______________________________
SECTION 4I       N/A Dietitian Action: Monitor labs, weight & weight changes, and other parameters Nutrition Education Provided
   Refer to plan of care   Counsel patient on ways to increase calorie and protein intake       Counsel on weight loss through diet/exercise
   Encourage use or increased use of nutritional supplements        Refer to MSW for financial/community resources Refer MD follow up
Labs/graphics discussed with Nursing home          Caregiver/family Patient             Other_________________________________________
SECTION 4J        N/A     Fluid Control (Goal: Fluid gain <= 5% of EDW) EDW: ___________ kg              Average fluid gains: _______ kg
Action: Monitor weight gains q TX            Patient education on sodium/fluid/glycemic control and signs of fluid over     Re-evaluate EDW
    Refer to plan of care    Other_______________________________________________________________________________________
Comprehensive Interdisciplinary Patient Assessment - MONTHLY/UNSTABLE                                                            Page 8 of 11
Patient Name/Label: _______________________________________________________Admission Date: _____________________
SECTION 5                                  SOCIAL SERVICE ASSESSMENT
SECTION 5A         N/A
Advance Directives      No       Yes, Copy in chart Appointee Name:_______________________________________________________
   Do Not Resuscitate order at Facility     No    Yes         Do Not Resuscitate order in Community       No     Yes
   Pre-funeral arrangements No           Yes, Funeral home Name:______________________________________Phone__________________
   Court Appointed Guardian       No      Yes, Appointee Name:________________________________________________________________
   Financial Durable Power of Attorney       No     Yes, Name:________________________________________________________________
  Information given to patient/family Date Provided____________________          Patient Declines / Not Interested
  Discussed Other _______________________________________________________________________________________________
SECTION 5D        N/A                                                      Current Employment       N/A
Prior Employment If initial-use 6 months prior to starting dialysis           Employed Full Time      Employed Part Time       Retired
    Employed Full Time      Employed Part Time          Retired               Medical Leave of Absence      Not employed - By Choice
    Medical Leave of Absence       Not employed - By Choice                   Not Employed – Disabled       Not Employed – Looking for Work
    Not Employed – Disabled        Not Employed – Looking for Work           Normal Age retirement          Medical Retirement
   Normal Age retirement           Medical Retirement
SECTION 5E          N/A
Vocational Rehabilitation Status If not working          Enrolled in a Vocational rehab agency      Referred to a Vocational rehab agency
   Interested, but has not followed up         Not interested       Not eligible     Pursuing a vocational interest     Developing Self-Help Skills
Are there barriers identified preventing positive vocational outcomes?        No     Yes , Explain Barriers_________________________________
SECTION 5F          N/A
Living Status       Home        Condo       Mobile home      Apartment        Rents House        Assisted Living    Homeless
    Public Housing       Shelter ___________________________         Long-Term care Facility (SNF) __________________________________
    Acute Rehabilitation Center____________________________ Correctional Facility __________________________________________
    Adult Family Home__________________________________              Adult Group Home __________________________________________
With whom does the patient live?             Lives alone      Parents         Spouse          Child/Children     Significant other
    Significant Friend     Significant Relative     Other_______________________________________________________________________
Is the current living situation a barrier to positive treatment outcomes?      No      Yes, Describe_________________________________
_____________________________________________________________________________________________________________________
SECTION 5G        N/A Social Status:
 Income                  No problems                   Maximum Assistance in place            Referral needed                Referral in process
Food                     No problems                   Maximum Assistance in place            Referral needed                Referral in process
Medication               No problems                   Maximum Assistance in place            Referral needed                Referral in process
Utilities                No problems                   Maximum Assistance in place            Referral needed                Referral in process
Housing/rental           No problems                   Maximum Assistance in place            Referral needed                Referral in process
Legal                    No problems                   Maximum Assistance in place            Referral needed                Referral in process
Immigration              No problems                   Maximum Assistance in place            Referral needed                Referral in process
Other                    No problems                   Maximum Assistance in place            Referral needed                Referral in process
Other                    No problems                   Maximum Assistance in place            Referral needed                Referral in process
Comprehensive Interdisciplinary Patient Assessment - MONTHLY/UNSTABLE                                                                Page 9 of 11
Patient Name/Label: _______________________________________________________Admission Date: _____________________
SECTION 5 – PART A                             SOCIAL SERVICE ASSESSMENT
SECTION 5 – PART A1           N/A
  Mobility Status and Activities of Daily Living:
Ambulatory assistance:       None       Cane/crutch         Walker    Manual Wheelchair       Electric wheelchair    Limb prosthesis ____________
Level of Assistance with Activities of Daily Living      Independent      Requires total care
Assistance required for:    Bathing          Toileting      Dressing     Medication Management          Meal Preparation     House keeping
    Laundry      Transportation       Shopping        Finances      Medical Appointments       Other:______________________________________
Is there adequate support or services in place to provide assistance?            No        Yes, Describe_________________________________
___________________________________________________________________________________________________________________

SECTION 5 – PART A3           N/A
Support System and Spirituality What is the patient’s relationship status?    Domestic partner       Married     Divorced       Single
    Widowed        Separated Describe family composition: ____________________________________________________________________
What is the level of involvement of family and friend on a regular basis:      Daily     Weekly    Monthly      Less frequently than monthly
How does the patient cope with life events and dialysis stress?        Keeps it to him/herself   Talk to family    Talk to friends     Pray
    Talk with a professional     Support group     Resources on the internet     Other______________________________________________
Is the patient involved in community activities, groups, social events or volunteering?        No       Yes, Describe___________________
____________________________________________________________________________________________________________________
What has the patient previously done for enjoyment or recreation? __________________________________________________________
____________________________________________________________________________________________________________________
Is (s) he able to engage in these activities now?       No       Yes
Is the patient part of a spiritual or religious community      No      Yes, Describe______________________________________________
___________________________________________________________________________________________________________________
Are there any specific cultural or spiritual practices/restrictions?    No       Yes, Describe____________________________________
____________________________________________________________________________________________________________________
SECTION 5 – PART A4         N/A
Cognitive Patterns & Cognitive Skills Is there evidence of a change in cognitive status from the patient’s baseline since the last assessment?
(initial assessment, compare to reported status 6 months prior to starting dialysis treatments)       No        Yes
The patient makes decisions regarding tasks of daily life:         Independent – decisions consistent and reasonable
     Modified independence – some difficulty in new situations       Moderately impaired – decisions poor, cues/supervision required
     Severely impaired – never/rarely makes decisions
Does the patient appear to have a problem with the following? Short Term Memory                  No        Yes        Long term Memory     No        Yes
If yes, the patient was normally able to recall the following during the last 5 days:
     Current Season        Day of the Week        Staff names and faces         That ( s )he is in a dialysis facility     None of the above is recalled
SECTION 5 – PART A5            N/A
                                                                                                            Behavior             Behavior present,
                                                                                       Behavior           continuously          fluctuates (comes
                                     Behavior
                                                                                      not present         present does          and goes, changes
                                                                                                          not fluctuate             in severity
Inattention – Did the patient have difficulty focusing attention (easily distracted,
out of touch, or difficulty keeping track of what was said)?
Disorganized thinking – was the patient’s thinking disorganized or incoherent
(rambling or irrelevant conversation, unclear or illogical flow of ideas, or
unpredictable switching from subject to subject)?
Altered Level of consciousness – Did the patient have altered level of
consciousness (Not related to low blood pressure)?
Psychomotor retardation – Did the patient have an unusually decreased level
of activity (sluggishness, staring into space, moving slowly)?
What sources of information were used in answering this section?
    Patient’s self-report      Medical records       Observations of dialysis staff    Social supports/family Other:_______________________
Does the patient’s behavior change during dialysis treatments?                No     Yes, describe_______________________________________
___________________________________________________________________________________________________________________
Comprehensive Interdisciplinary Patient Assessment - MONTHLY/UNSTABLE                                                     Page 10 of 11
Patient Name/Label: _______________________________________________________Admission Date: _____________________
SECTION 5 – PART A 6        N/A         SOCIAL SERVICE ASSESSMENT
Mental Health Status – Does the patient report any past or current mental health issues, concerns or mode disturbances (feeling of
depression or anxiety?      No       Yes, describe_______________________________________________________________________
    Unknown – Reason______________________________________________________________________________________________
Is there any history of mental health diagnosis?     No      Yes, record below
                            Diagnosis                                                   Approximate Date of Diagnosis



Has the patient participated in counseling?     No       Currently in counseling (describe)      Yes, in the past (describe)
___________________________________________________________________________________________________________________
Has the patient ever taken a psychotropic medication? (med to relax, sleep or feel less sad)    No       Yes,
describe____________________________________________________________________________________________________________
Are there signs/symptoms present for depression or anxiety problems?        No       Yes, complete signs and symptoms below
                       SECTION 5 – PART A 7         N/A                                                Severity Level
                           Signs and Symptoms                                         Not a
                                                                                                       Mild         Moderate       Severe
                                                                                    Problem
Depressed mood most of the day
Decreased interest/pleasure in most activities
A problem with appetite/weight change
Significant sleep disturbance
Psychomotor retardation or agitation
Fatigue, loss of energy
Feelings of worthlessness or guilt
Poor concentration
Suicidal ideation
Panic attacks
Irritable mood
Early awakening
This signs/symptoms list is not comprehensive and is not intended to diagnosis depression, Further assessment should be completed if
signs/symptoms are present. Somatic symptoms may be due to medical causes.
SECTION 5 – PART A 8          N/A Has the patient started taking a psychotropic medication?            No      Yes, note below
                                                                                                           Not        Adverse        Not Yet
                       Medication and Dosage                            Date Started     Effective
                                                                                                        Effective     Reaction    Determined




SECTION 5 – PART A 9             N/A
Has the patient started counseling or a support group?          No      Yes, Describe______________________________________________
___________________________________________________________________________________________________________________
SECTION 5 – PART A 10             N/A If Unable to interview patient specific reason:   Yes      No,
Describe____________________________________________________________________________________________________________
SECTION 5 – PART A 11             N/A Say to the patient: “Over the past two weeks, have you often been
bothered
                                                                                                               Yes           No
Little interest or pleasure in doing things?
Feeling low, depressed, or hopeless?
Comprehensive Interdisciplinary Patient Assessment - MONTHLY/UNSTABLE                                                            Page 11 of 11
Patient Name/Label: _______________________________________________________Admission Date: _____________________
                                          SOCIAL SERVICE ASSESSMENT
SECTION 5 – PART B6          N/A                                               Very       Somewhat         Neither easy    Somewhat            Very
Patient Interview: “Over the past month, how easy or                 N/A
                                                                               Easy         Easy           nor Difficult    Difficult         Difficult
difficult has it been for you to do any of the following?”
Come to each hemodialysis treatment.
Complete the full-prescribed hemodialysis treatment time.
Perform every peritoneal dialysis treatment.
Take medications as prescribed.
Follow dietary restrictions.
Follow fluid restrictions

SECTION 5 – PART B7        N/A
What is the number of percentage of shortened treatments in the last 30 days? _________              N/A

SECTION 5 – PART B8           N/A
Does patient appear comfortable asking staff/physician questions?       N/A        Yes       No
                                             Does not know what questions to ask                                  Cannot speak
If NO, what factors limit the patient’s
                                             Does not speak English or any language staff speak                   Limited Cognitive ability
comfort in asking questions?
                                             Thinks asking questions is disrespectful                             Other
                                              Comprehensive Interdisciplinary Signatures:
                                                                                                                                  Date:
Nephrologist
Signature:
                                                                                                                                  Date:
Nurse
Signature:
                                                                                                                                  Date:
Dietitian
Signature:
                                                                                                                                  Date:
Social Worker
Signature:
                                                                                                                                  Date:
Transplant
Signature:
                     N/A – Refer to Transplant status/ medical record – Co morbid condition contra-indication for transplant
                                                                                                                                  Date:
Patient
Signature:
                           Members of the multidisciplinary team additional comments as desired
                                            (Date and Sign each note below)
     Date                                                      Comments

				
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posted:10/21/2011
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