NHS No Date of Birth
Family Name Forename
LONDON HEALTH NEEDS ASSESSMENT
With thanks to NHS South East Coast - Adapted from NHS London’s Health Needs Assessment and the
Single Assessment Process of NHS South East Coast.
Assessment Principles
In line with the revised National Framework for NHS Continuing Healthcare, this Health Needs
Assessment must accompany a social care assessment and other individual specialist
assessments from Allied Health Professionals etc. to form a Comprehensive Multi-Disciplinary
Assessment. This document indicates where additional specialist assessments may be required
by use of this symbol *.
Agencies should ensure that suitably qualified & competent staff are available to undertake
assessments and that more qualified or specialist professionals can be readily accessed if more
specialist assessment or investigation is needed. (Reference: National Service Framework for
Older People Standard 2001)
Those staff carrying out the assessment will need to be experienced and skilled in assessment
practice and multidisciplinary working. They should be familiar with the needs of the individual.
(Reference: National Service Framework for Older People Standard 2001)
The person being assessed should always be treated as an individual. To ensure consistent
access, assessments should be:
o Culturally sensitive
o User centred
o Equitable
The individual (and their carers/advocates – reference Mental Capacity Act) should be consulted
and fully involved in the assessment process.
The timing and location of an assessment is important and due regard should be given to further
rehabilitation potential and the outcome of any treatments or medications which may affect the
on going needs of the individual.
The assessment should accurately, clearly and comprehensively detail the individuals needs
and risks.
The multi-disciplinary assessment should be in a format such that it can also be used to assist
PCT’s and LA’s to meet care needs regardless of the outcome of the eligibility consideration for
continuing healthcare. The assessment process should include referral for specialist
assessments and also make use of existing such assessments wherever it is appropriate in the
light of the individual’s care needs.
As stated above, this is not a stand alone document. This Health Needs Assessment is just one
part of the multi-disciplinary assessment required before a full consideration of Continuing
Healthcare can take place and the DST can be completed. The minimum data set to be taken
into account before the Decision Support Tool (DST) can be completed must include a social
work assessment and a health needs assessment.
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
1/27
NHS No Date of Birth
Family Name Forename
Date of Commencement of Assessment:
Health Needs Assessment
Personal Information
Name: (title / first name(s) / last name)
Date of birth :
Permanent
Address:
Gender:
Referrer:
Phone No:
Lead Health
Co-ordinator
Current Address
(if not permanent
Name:
address):
Contact Details
Is English the
If not what is the
individual’s first Yes No
first language?
language?
Has the individual, main carer or advocate been given written information about the Continuing
Yes No
Healthcare process?
Has the Continuing Healthcare process been explained to the individual, main carer or advocate? Yes No
Was the individual involved in the completion of the Health Needs Assessment? Yes No
Was the individual offered the opportunity to have a representative such as a family member or
Yes No
other advocate present when the Health Needs Assessment was completed?
If yes, did the representative attend the completion of the Health Needs Assessment? Yes No
Name :
Address:
Please give the contact details of
the representative
Telephone No:
Relationship to
patient:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
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NHS No Date of Birth
Family Name Forename
EQUALITY MONITORING
About You
Please provide us with some information about yourself. This will help us to understand whether everyone is receiving fair and
equal access to NHS continuing healthcare. All the information you provide will be kept completely confidential. No identifiable
information about you will be passed on to any other bodies, members of the public or press.
(1) What is your sex?
Male Female Transgender
Tick one box only
0-15 16-24 25-34 35-44 45-54
(2) Which age group applies to you?
Tick one box only
55-64 65-74 75-84 85+
(3) Do you have disability defined by the Disability Discrimination Act (DDA)?
The Disability Discrimination Act (DDA) defines a person with a disability as someone who has Yes No
a physical or mental impairment that has a substantial and long-term adverse on his or her
ability to carry out normal day-to-day activities.
A - White
British Irish Any other White background, write below
B - Mixed
White and Black Caribbean White and Black African
White and Asian Any other Mixed background, write below
C – Asian, or Asian British
Indian Pakistani Bangladeshi Any other Asian background, write
(4) What is your ethnic group? below
Tick one box only
D – Black, or Black British
Caribbean African Any other Black background, write below
E – Chinese, or other ethnic group
Chinese Any other, write below
(5) What is your religion or belief?
Tick one box only
Christian includes Church of Wales, None Christian Buddhist Hindu Jewish Muslim Sikh
Catholic, Protestant and all other
Christian denominations
Heterosexual/Straight Lesbian/Gay Woman Gay Man
(6) Which of the following best Bisexual Prefer not to answer Other, write below
describes your sexual orientation?
Tick one box only
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
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NHS No Date of Birth
Family Name Forename
CONSENT TO THE ASSESSMENT PROCESS & INFORMATION SHARING
If there is a concern that the individual may not have capacity to give their consent, this should be determined in accordance
with the Mental Capacity Act 2005 and the associated code of practice. Those completing assessments or the DST should
particularly be aware of the five principles of the Act:
A presumption of capacity – every adult has the right to make his or her own decisions and must be assumed to have capacity
to do so unless it is proved otherwise;
Individuals being supported to make their own decisions – a person must be given all practicable help before anyone treats
them as not being able to make their own decisions;
Unwise decisions – just because an individual makes what might be seen as an unwise decision, they should not be treated as
lacking capacity to make that decision;
Best interests – an act done or decision made under the Act for or on behalf of a person who lacks capacity must be done in
their best interests; and
Least restrictive option – anything done for or on behalf of a person who lacks capacity should be the least restrictive of their
basic rights and freedoms.
Mindful of this who holds formal decision making responsibility?
Self or Other? Self Other (as below) Date decision made:
Health/welfare
Lasting PoA: Level of power:
Financial
Health/welfare
Deputy: Level of power:
Financial
Enduring PoA:
Additional Info:
Advanced decision to refuse treatment? Yes No Date decision made:
Located where?
Has this person got capacity?
Yes No
If Yes - has their consent been obtained for this assessment?
Yes No
Have they given consent to have information shared with their next of kin, main carer or
Yes No
advocate?
Has their consent been obtained for sharing information contained within this assessment with
Yes No
potential care providers?
If the person is deemed to not have capacity
to consent, how was their capacity
determined? How and by whom has it been
decided that it is in the person’s best interests
to complete this assessment?
SIGNATURE OF ASSESSED PERSON:
SIGNATURE OF ASSESSED PERSON’S REPRESENTATIVE:
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
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NHS No Date of Birth
Family Name Forename
This section should be completed by a registrar or above in a hospital setting
or in a community setting it should be completed by a GP or advanced nurse practitioner.
DIAGNOSIS SUMMARY
What are their current major diagnosis & problems (including management/treatment plan including the need for
specialist review)?
Describe below - How stable is their condition?
Explain how the current health conditions impact on the individuals ability to undertake activities of daily living,
include the individuals perspective:
Where the assessed person is in hospital, please give
the Consultants name and specialty:
Allergies:
Current Infection Control Status:
PREVIOUS MEDICAL HISTORY
Health History (please give dates). How was the person functioning prior to this assessment?
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
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NHS No Date of Birth
Family Name Forename
POTENTIAL FOR RECOVERY AND REHABILITATION?
Has this individual reached their full potential for recovery? Please refer to members of the Multi-Disciplinary Team
before completing this section. If the individual has NOT reached their full rehab potential do NOT continue with the
CHC process.
Sources of information:
INDIVIDUAL’S, CARER’S OR ADVOCATE’S PERCEPTION OF NEEDS
What is the Individual’s view of their needs (or if the individual has no capacity – then detail the carer’s or advocate’s
views)
SIGNATURE OF ASSESSED PERSON:
SIGNATURE OF ASSESSED PERSON’S REPRESENTATIVE:
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
6/27
NHS No Date of Birth
Family Name Forename
CURRENT AND RECENT HOSPITAL ADMISSIONS
Hospital/ ward Reason for Admission Admission Date Discharge Date
MOST RECENT GP INTERVENTIONS
Complete if applicable (particularly for individuals in the community)
Date Reason for Visit Treatment/Plan/Outcome
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
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NHS No Date of Birth
Family Name Forename
RISK
All appropriate risk assessments, which document both potential impact and likelihood, should be carried out to consider
relevant risks to the patient, carers or care workers and society. Evidence from these assessments should be attached to this
document and considered when deciding the level of need appropriate in each domain. Please use this box to draw attention
to any immediate risks pertaining to current care or health state. Indicate which, if any, of the risks are present and indicate if
significant. Record the severity/frequency/whom it involves.
Areas to consider
Risk To Self
Suicide
Deliberate self harm
Accidental self harm
Self neglect
Addiction (alcohol /drugs)
Wandering
Falls
Risk To Others
Physically violent
Threat of violence
Verbally abusive
Sexually inappropriate
behaviour
Vulnerability From Others
Financial abuse
Physical abuse
Emotional abuse
Sexual abuse
Social isolation
Unstable Mental State
Mental health liable to
deteriorate quickly or
unpredictably
Compliance Problems
Refusing nursing/therapy
intervention
Other Risks
(Please specify)
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
8/27
NHS No Date of Birth
Family Name Forename
BEHAVIOUR
* Please attach current supporting mental health risk assessments/care plans/behaviour charts
Please explain below in detail the types/ patterns/ triggers/ frequency of behaviours, required interventions and
effectiveness of care plan:
CLINICAL PICTURE
Does the person Sources of
display: information:
Disinhibition Daily At least weekly Less than weekly/infrequently Never
Persistent noisiness Daily At least weekly Less than weekly/infrequently Never
Persistent restlessness Daily At least weekly Less than weekly/infrequently Never
Resistance to care Daily At least weekly Less than weekly/infrequently Never
Interference with Daily At least weekly Less than weekly/infrequently Never
others
Inappropriate sexual Daily At least weekly Less than weekly/infrequently Never
behaviour
Inappropriate urination Daily At least weekly Less than weekly/infrequently Never
Faecal Smearing Daily At least weekly Less than weekly/infrequently Never
At night, does the
person display:
Restlessness Daily At least weekly Less than weekly/infrequently Never
Wandering Daily At least weekly Less than weekly/infrequently Never
Need for sedation Daily At least weekly Less than weekly/infrequently Never
Has the person been Daily At least weekly Less than weekly/infrequently Never
physically violent?
Do they threaten Daily At least weekly Less than weekly/infrequently Never
violence?
Are they verbally Daily At least weekly Less than weekly/infrequently Never
abusive?
Details :
Is the individual subject to any Section of the Mental Health
Act? If so which one?
If so please make sure you understand the guidance before you
consider the individual for Continuing Healthcare Funding. Refer to
National Framework for Continuing Healthcare , section 112 ‘Links
to other policies’
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
9/27
NHS No Date of Birth
Family Name Forename
COGNITION
Please comment on the individual’s ability to make decisions on a day-to-day basis (capacity); comprehension and
ability to receive and understand information. Please comment if this individual requires an Independent Mental
Capacity Advocate.
Are there other factors that make this difficult to assess? E.g. communication, psychological & emotional needs,
behaviour etc.
* Please attach any cognitive assessments e.g. mini mental state examination
CLINICAL PICTURE
Is the person:
Disorientated in time Always Mostly Occasionally Infrequently Never
Disorientated in place Always Mostly Occasionally Infrequently Never
Disorientated to person Always Mostly Occasionally Infrequently Never
Confused Always Mostly Occasionally Infrequently Never
Has the individual been assessed and diagnosed by a GP or psychiatrist to indicate they are
suffering from organic mental illness (e.g. dementia) which has affected their cognitive Yes No
functioning
Other sources of information:
Has an Abbreviated Mental Score:
Test, Mini Mental State
Examination or other Date test completed:
validated test been carried
out? Completed by?
If not please arrange for one to Name:
be done before proceeding with
this assessment Designation:
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
10/27
NHS No Date of Birth
Family Name Forename
MINI MENTAL STATE EXAMINATION
Score ( /30)
1. Orientation
What is the year? ( /1) Season? ( /1)
What is the date? ( /1) Day? ( /1)
What is the month? ( /1)
2. Where are we?
Country? ( /1) County? ( /1)
Town? ( /1) Hospital? ( /1)
Floor? ( /1)
3. Registration
Name three objects, taking one second to say each. Then ask the person all three after
you have said them. Give one point for the correct answer. Repeat the answers until
the person learns all three. ( /3)
4. Attention & Calculation
Serial sevens. Give one point for each correct answer. Stop after five answers
(Alternative: spell WORLD backwards). ( /5)
5. Recall
Ask for names of three objects learned in Question 3 (above)
Give one point for each correct answer ( /3)
6. Language
Point to a pencil and a watch. Have the person name them as you point ( /2)
7. Have the person repeat “No ifs, ands or buts” ( /1)
8. Have the person follow the three-stage command, “Take the paper in your right hand.
Fold the paper in half. Put the paper on the floor”. ( /3)
9 Ask the person to read and obey the following: “Close your eyes” ( /1)
10. Ask the person to write a sentence of his or her own choice (sentence should contain a
subject, object & make sense. Ignore spelling) ( /1)
11. Show the design printed below to 1.5 cm per side, and ask the person to copy it (give
one point if all sides and angles are preserved & if the intersecting sides form a ( /1)
quadrangle
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
11/27
NHS No Date of Birth
Family Name Forename
PSYCHOLOGICAL & EMOTIONAL NEEDS
Explain below the individual’s mood, any periods of distress and anxiety symptoms, including identified trigger
factors.
CLINICAL PICTURE
Is the person:
Withdrawn Always Mostly Occasionally Infrequently Never
Depressed Always Mostly Occasionally Infrequently Never
Distressed Always Mostly Occasionally Infrequently Never
Does the person:
Respond to pleasant events Always Mostly Occasionally Infrequently Never
Have episodes of sadness Always Mostly Occasionally Infrequently Never
Describe below any interventions used (medication or therapy) and the individual’s ability to participate in their care
plan.
Please comment on your professional view of the
individual’s insight
Does the individual know
What is the individual’s he/she needs help?
insight into their care
needs/illness? Yes No
Other sources of information:
Has the person had a
Yes No
specialist psychological
(If yes, provide evidence below)
assessment?
Has a Geriatric Depression
If yes - what was the score?
Scale, 'Cornell Scale’ for
assessing depression in
Yes No Date of test:
people with dementia or
other validated test been
Which Test completed?
completed?
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
12/27
NHS No Date of Birth
Family Name Forename
THE GERIATRIC DEPRESSION SCALE
(If person is unable to participate please complete the
Cornell Scale for Depression on the next page)
Answer all the following questions by ringing wither ‘Yes’ or ‘No’
1. Are you basically satisfied with your life? Yes / No
2. Have you dropped many of your activities and interests? Yes / No
3. Do you feel that your life is empty? Yes / No
4. Do you often get bored? Yes / No
5. Are you in good spirits most of the time? Yes / No
6. Are you afraid that something bad is going to happen to you? Yes / No
7. Do you feel happy most of the time? Yes / No
8. Do you often feel helpless? Yes / No
9. Do you prefer to stay at home, rather than going out and Yes / No
doing new things?
10. Do you feel you have more problems with memory than most? Yes / No
11. Do you think it is wonderful to be alive now? Yes / No
12. Do you feel pretty worthless the way you are now? Yes / No
13. Do you feel full of energy? Yes / No
14. Do you feel that your situation is hopeless? Yes / No
15. Do you think that most people are better off than you are? Yes / No
TOTAL SCORE:
Score 1 point for each italicised answer. A total score of 6 – 15 suggests depression.
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
13/27
NHS No Date of Birth
Family Name Forename
The Cornell Scale for Depression
Alternative scale for persons who are unable to participate in the Geriatric Depression Scale
Ratings should be given based on signs and symptoms SCORE
occurring during the week prior to interview. No score a 0 1 2
should be given in symptoms resulting from physical Unable to Absent Mild or Severe
disability or illness evaluate intermittent
A. Mood-related signs
1. Anxiety - anxious expression, ruminations, worrying
2. Sadness – sad expression, sad voice, tearfulness
3. Lack of reactivity to pleasant events
4. Irritability – easily annoyed, short tempered
B. Behavioural disturbances
5. Agitation – restlessness, hand wringing, hair pulling
6. Retardation – slow movements, slow speech, slow
reactions
7. Multiple physical complaints (score 0 if GI symptoms
only)
8. Loss of interest – less involved in usual activities
(score only if change occurred acutely i.e. less than
1 month)
C. Physical signs
9. Appetite loss (eating less than usual)
10. Weight loss (score 2 if greater than 5lb or 2.25kgs in
1 month)
11. Lack of energy – fatigues easily, unable to sustain
activities (score only if change occurred acutely i.e.
less than 1 month)
D. Cyclic functions
12. Diurnal variation of mood, symptoms worse in
morning
13. Difficulty falling asleep
14. Multiple awakening during sleep
15. Early morning awakening (earlier than usual)
E. Ideational disturbance
16. Suicide – feels like life is not worth living, has
suicidal wishes has made suicidal attempts
17. Poor self esteem – self blame, self deprecation,
feelings of failure
18. Pessimism, (anticipation of the worse)
19. Mood-congruent delusions – delusions of poverty,
illness or loss
TOTAL SCORE:
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
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NHS No Date of Birth
Family Name Forename
COMMUNICATION
Comment on the individual’s ability to express their needs, including verbal and non-verbal methods of
communication and interventions required. Explain what can support their communication needs.
* Include any assessments undertaken by the Speech and Language Therapist
VERBAL: NON VERBAL:
Insert comments here: Insert comments here:
CLINICAL PICTURE
Is the person:
Able to express self Always Mostly Occasionally Infrequently/Never
Able to understand instructions Always Mostly Occasionally Infrequently/Never
Able to make needs known (orally) Always Mostly Occasionally Infrequently/Never
Able to make needs known Always Mostly Occasionally Infrequently/Never
(non-orally)
If you answer yes to the questions below please give comments:
Does the person have a hearing
Yes No
impairment?
Does the person have a visual
Yes No
impairment?
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
15/27
NHS No Date of Birth
Family Name Forename
MOBILITY
* Attach/reference current moving and handling, falls and risk assessments, including Physiotherapist and Occupational
Therapist report.
Describe the actual needs of the individual. How many people are needed to transfer/support the individual’s mobility? Explain
what they need to do. What the equipment is for i.e. use of wheelchair for transfer only:
CLINICAL PICTURE
Does the person have sitting Can the person
Yes No Assisted Yes No Assisted
balance? weight bear?
Does the person use a Yes No
wheelchair? (If yes, is the wheelchair Electric, Manual – Independent or Manual – Supported)
Independently With the use of aids, if yes – please specify in comments box below
Can the person walk?
With assistance of 1 With assistance of 2 Unable/NA
Independently With the use of aids, if yes – please specify in comments box below
Can the person climb stairs? With assistance of 1 With assistance of 2 Unable/NA
Can the person get in and Independently With the use of aids, if yes – please specify in comments box below
out of bed? With assistance of 1 With assistance of 2 Unable/NA
Can the person get on and Independently With the use of aids, if yes – please specify in comments box below
off a chair? With assistance of 1 With assistance of 2 Unable/NA
Can the person get on and Independently With the use of aids, if yes – please specify in comments box below
off the toilet? With assistance of 1 With assistance of 2 Unable/NA
Does the person require Independently With the use of aids, if yes – please specify in comments box below
positioning in bed? With assistance of 1 With assistance of 2 Unable/NA
Please comment on the
person’s upper limb function
Does the person have a
complex sitting position? Yes No Please include the physio / OT assessment for any specialist aids
Type of mobility aid used Has it been provided?
If the person requires
mobility equipment, specify
the type and for what
purpose
Mobility Prognosis Likely to improve Stable Deteriorating
Yes No (If yes detail the history of falls below, indicating when falls occurred, how
Has the person fallen?
frequently the person has fallen, and the reason why the falls have occurred)
When did fall occur? How did it happen?
Falls History
Risk Assessments attached? Yes No Reason if not attached?
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
16/27
NHS No Date of Birth
Family Name Forename
NUTRITION – FOOD AND DRINK
Please comment on the individual’s ability to maintain their nutritional status.
Please detail Body Mass Index/weight history and any concerns regarding nutritional status. If unable to measure
height, use one of the alternative measurements to estimate height (ulna, knee height or demispan).
* If this individual has dysphagia please attach a copy of any recent Speech & Language Therapy assessment/care plan.
* If this individual has unintentional weight loss, attach the Dieticians Assessment/care plan.
CLINICAL PICTURE
Can the person feed
Yes Needs food cutting up Needs supervision/prompting Needs feeding
themselves?
What consistency of
Normal Pureed Soft Mixed
food is required?
If yes, is this:
PEG NG (If NG will it be removed before discharge? Yes No)
Does the person
Yes No
require feeding aids?
TPN Jejunostomy Other, please specify:
(State in the comments box if this requires skilled assessment and review)
Can the person drink
Yes Needs supervision/prompting Needs assistance
independently?
Is the person at risk of
What consistency of Yes No (If yes detail the
Normal Thickened choking whilst
fluids is required? management plan in the comments box)
eating/drinking?
Has there been recent
Yes No Not Known (If yes detail the weight change and time period below)
weight gain/loss?
Weight at time of Height at time of BMI at time of
assessment? assessment? assessment?
Has a Malnutrition Universal
Screening Tool (MUST) been Yes No (If yes, complete box below)
completed?
Score: Date: Name and designation of assessor:
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
17/27
NHS No Date of Birth
Family Name Forename
MUST (Malnutrition Universal Screening Tool)
Weight Kg Height m
Previous recorded Kg Date previous
weight weight recorded
Measurement Scores (please score as indicated) Score
BMI kg/m2 >20.0 = 0
18.5 – 20.0 = 1
10% = 2
Acute Disease Effect
Add a score of 2 if there has been or is likely to be no or very little nutritional intake
for > 5 days
MUST SCORE
OVERALL RISK OF MALNUTRITION (Please Circle)
Low = 0 Medium = 1 High =2 or more
ROUTINE CLINICAL CARE OBSERVE TREAT
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
Alternative Height Measurement:
Conversion of ulna length (cm) to height (m)
Men
1.94 1.93 1.91 1.89 1.87 1.85 1.84 1.82 1.8 1.78 1.76 1.75 1.73 1.71 1.69 1.67 1.66 1.64 1.62 1.6 1.58 1.57 1.55 1.53
(65)
Women
1.84 1.83 1.81 1.8 1.79 1.77 1.76 1.75 1.73 1.72 1.7 1.69 1.68 1.66 1.65 1.63 1.62 1.61 1.59 1.58 1.56 1.55 1.54 1.52
(65)
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
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NHS No Date of Birth
Family Name Forename
CONTINENCE
Please describe the individual’s continence needs/management including any health related issues such as recurrent
urinary tract infections/fluctuating bowel habits/risk factors/severe constipation.
*Consider if there is a need for a specialist continence assessment.
CLINICAL PICTURE
Is the person affected by: (tick all that apply)
Frequency (Voids more than 7 times a day / or more than twice per night)
Urgency (Urgent desire to void and cannot wait to go to the toilet)
Nocturia (Woken up with desire to pass urine)
Incontinence, bladder or bowel (Any leakage or soiling)
Voiding difficulties (Symptoms of hesitancy, straining, poor stream)
Chronic Diarrhoea (not related to acute infection such as gastroenteritis or food poisoning)
Constipation
Does the person have a spinal injury requiring digital stimulation
If catheterised give details:
Is the person catheterised?
Supra pubic
Urethral
Yes No
Other?
Is the person able to self catheterise? Yes No
Does the person have a Does the person suffer from chronic UTIs? Yes No
Stoma/ Urostomy? (Please give history below)
What treatment was required (include
Yes No When did the UTI occur
whether person was hospitalised)
Please state type:
Is the person able to self-manage
the Stoma?
Yes No
(Give details in comments box above
if appropriate)
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
19/27
NHS No Date of Birth
Family Name Forename
SKIN (INCLUDING TISSUE VIABILITY)
Detail any evidence of broken/compromised skin conditions (whether pressure ulcers/ wounds/other). Explain how the
wounds originated (e.g. pressure points, surgery). Record the treatment regime in place and advise if the wound(s)/skin
condition(s) are responding to treatment or continue to deteriorate.
*Attach any Tissue Viability Nurse Specialist assessment(s).
CLINICAL PICTURE
Does the person have pressures sores or other open
Yes No
wounds?
If yes, describe grade, site, measurements, and
frequency and type of dressings (below):
Are the wounds healing? Describe below
Sources of information:
Does the person require equipment to maintain skin
Yes No
integrity
If yes detail here:
Does the person require positioning/turning? Yes No
If yes how often?
Does the person have a diagnosed skin condition? (If
Yes No
yes, detail condition and management plan below)
Has a Waterlow, Walsall or other validated test Yes No
been completed? (If yes, complete boxes below)
Score: Date: Name and designation of assessor:
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
20/27
NHS No Date of Birth
Family Name Forename
WATERLOW RISK ASSESSMENT TOOL
Ring scores in table and total. Several scores per category can be used
BUILD/WEIGHT SKIN TYPE SEX SPECIAL RISKS
FOR HEIGHT (visual risk AGE
areas)
Average 0 Healthy 0 1 e.g.
Male
Above average 1 Tissue paper 1 2 Terminal 8
Female
cachexia
Obese 2 Dry 1 14 - 49 1 Cardiac failure 5
Below average 3 Oedematous 1 50 – 64 2 Peripheral 5
vascular disease
Clammy (temp) 1 65 – 74 3 Anaemia 2
Discoloured 2 75 – 80 4 Smoking 1
Broken/spot 3 81+ 5
CONTINENCE MOBILITY APPETITE NEUROLOGICAL
DEFICIT
0 Fully 0 Average or 0 e.g.
Complete/
stable on
catheterised
PEG feed
Occasional 1 1 Poor 1 Diabetes, MS, 4
Restless/
incontinence CVA, -
Fidgety Motor/sensory 6
paraplegia
Catheterised/ 2 Apathetic 2 Very poor 2
incontinent of
faeces
Doubly incontinent 3 Restricted 3 NBM/ 3 MEDICATION
anorexic
Inert/traction 4 Cytotoxics 4
High dose
steroids
Anti-
inflammatory
Chairbound 5
SCORE: 10+AT RISK, 15+ HIGH RISK, 20+ VERY HIGH RISK
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
21/27
NHS No Date of Birth
Family Name Forename
BREATHING
CLINICAL PICTURE
What is the respiratory condition?
Pulse BP
Respiratory Rate Drowsiness Yes No
SaO2 at rest Ankle Oedema Smoker ?
Yes No
Yes No
SaO2 on exertion Cyanosis Yes No
Temp Clubbing Yes No
Shortness of breath frequently each day Daily At least Weekly Less than Weekly/ Infrequently Never
Degree of breathlessness based on activity:
Not troubled by breathlessness except on strenuous exercise
Short of breath when hurrying on the level or walking up a slight hill
Walks slower than people of the same age on the level because of breathlessness or has to stop for breath
when walking at own pace
Stops for breath after walking about 100 metres or after a few minutes on the level.
Too breathless to leave the house or breathless when dressing or undressing
Cough Daily At least Weekly less than Weekly /Infrequently Never
Wheeze Daily At least Weekly less than Weekly /Infrequently Never
Sputum retention Daily At least Weekly less than Weekly /Infrequently Never
Chest Pain Daily At least Weekly less than Weekly /Infrequently Never
Nocturnal Breathlessness Daily At least Weekly less than Weekly /Infrequently Never
Anxiety Daily At least Weekly less than Weekly /Infrequently Never
Hypoxia Daily At least Weekly less than Weekly /Infrequently Never
Exacerbation of COPD State Frequency:
Recurrent Chest Infection State Frequency:
Respond to treatment? Please comment:
Management Plan
Pleural Effusion Yes No Please provide detail on management plan: including type
Self Management of intervention required, frequency and Intensity:
Yes No
Nebuliser Yes No
Prescription of antibiotics and/or
Yes No
steroids
Airway clearance techniques required Yes No
Provision of home oxygen Yes No
BiPAP Yes No
CPAP Yes No
Tracheotomy Yes No
Provision of home ventilation ( please
Yes No
state if Invasive or non invasive)
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
22/27
NHS No Date of Birth
Family Name Forename
DRUG THERAPIES AND MEDICATION
The location of care will influence who gives the medication. In determining the level of need, it is the knowledge and skill
required to manage the clinical need that is the determining factor. In some situations, an individual or their carer will be
managing their own medication and this can require a high level of skill.
Medication/Administration (use a continuation sheet if necessary)
Name Route Dosage Form Frequency
If any PRN medication is prescribed please comment on frequency given :
MEDICATION
Is the person compliant with their medication regime? Always Mostly Occasionally Infrequently/Never
What is the person’s condition with regard to their
Stable Unstable
medication regime?
What is the review date for the medication?
Is further specialist assessment indicated? Yes No
Is the person:
In need of Carer Supervision Administration
Able to self medicate
What level of supervision is required?
In need of Trained Nurse: Administration Monitoring
Explain why? Is this because the registration of the care home requires it, or because of the actual knowledge & skill required
to manage the clinical need?
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
23/27
NHS No Date of Birth
Family Name Forename
DRUG THERAPY & MEDICATION (PAIN & SYMPTOM CONTROL)
The individual’s experience of how their pain and other symptoms (where these symptoms are not accounted for in other domains
such as the Altered States of Consciousness and Psychological and Emotional Domains) are managed and the intensity of those
symptoms is an important factor in determining the level of need in this area. Where this affects other aspects of their life, please
refer to the other domains especially the psychological and emotional domain. The location of care will influence who gives the
medication. In determining the level of need, it is the knowledge and skill required to manage the clinical need that is the
determining factor. In some situations, an individual or their carer will be managing their own medication and this can require a
high level of skill.
CLINICAL PICTURE
Pain Management
Where pain is present, a detailed clinical assessment of the multidimensional aspects of pain should be undertaken including:
sensory dimension: the nature, location and intensity of pain
affective dimension: the emotional component and response to pain
impact: on functioning at the level of activities and participation
Does the person describe themselves as being in pain? (If yes,
Yes No
define the location and extent of pain on the pain map below)
Comments:
Sources of information:
Does the person experience breakthrough pain? Yes No
Are any PRN drugs in use? Yes No Frequency? Type?
Are there any other symptoms to control? e.g. Nausea; Fatigue – please describe below
Has a Numeric Graphic Rating Scale,
No Yes
Abbey Pain Scale, Pain Thermometer or Score (& test): Date:
If yes please attach
other validated test been completed?
Name and designation of assessor
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
24/27
NHS No Date of Birth
Family Name Forename
ALTERED STATES OF CONSCIOUSNESS (ASC)
CLINICAL PICTURE
Describe any evidence of altered states of consciousness. These include a range of conditions that affect
consciousness including Transient Ischemic Attacks (TIAs), Epilepsy, Vasovagal Syncope and Low Awareness State.
Please comment on care required and management. Include frequency and duration of altered states of consciousness,
identified risks to the individual and attach any seizure/coma scale charts as appropriate.
Comments:
Is there a causal link between a precipitating factor and the person’s altered states of consciousness? The factor (as
listed below):
Brain Injury Sources of information:
Stroke
Uncontrolled Orthostatic Hypotension
Syncope
Seizures
Transient Ischaemic Attack
Hypo/Hyperglycaemia
OTHER SIGNIFICANT CARE NEEDS TO BE TAKEN INTO CONSIDERATION
CLINICAL PICTURE
There may be circumstances, on a case-by-case basis, where an individual may have particular needs which do not fall into
the categories described above. Please give detail supported by evidence where possible of any other care needs not
described previously – an example would be Autonomic Dysreflexia
Please comment on the type and severity of need, including the impact on the individual:
Sources of information:
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
25/27
NHS No Date of Birth
Family Name Forename
THE BARTHEL ADL INDEX
This index should be used as a record of what a person does, NOT as a record of what a
person could do.
BOWELS 0 = Incontinent 1 = Occasional 2 = continence
incontinence
BLADDER 0 = incontinent or 1 = occasional accident 2 = continence (for
catheterised & (Maximum x 1 per 24 over 7 days)
unable to manage hours)
GROOMING 0 = Needs help 1 = Independent (with face/
hair/ teeth/ shaving)
TOILET USE 0 = dependent 1 = needs some help , but 2 = independent (on,
can do something off, dressing &
wiping)
FEEDING 0 = unable 1 = needs help (with 2 = independent
cutting, spreading butter
etc)
TRANSFER 0 = immobile 1 = major help (1-2 people, physical)
2 = minor help (verbal or 3 = independent
physical)
MOBILITY 0 = immobile 1 = wheelchair independent including
corners etc
2 = walks with help of 1 person 3 = independent (but may use any aid
(verbal or physical) e.g. stick)
DRESSING 0 = dependent 1 = needs help (verbal, 2 = independent
physical, carry aid)
STAIRS 0 = unable 1 = needs help (verbal, 2 = independent up and
physical, carry down) down
BATHING 0 = dependent 1 = independent
TOTAL SCORE /20
ASSESSOR: DESIGNATION:
SIGNATURE: DATE:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
26/27
NHS No Date of Birth
Family Name Forename
WHO HAS CONTRIBUTED AND AGREED TO THIS ASSESSMENT?
Name Role/Title Signature Date
IMPORTANT:
The minimum data set to be taken into account before the Decision Support Tool (DST) can be completed
must include a social work assessment and a health needs assessment.
INDIVIDUAL’S AGREEMENT THAT THEY HAVE BEEN INVOLVED IN AND UNDERSTAND THE OUTCOME
OF THE ASSESSMENT.
Please note that this must be completed or an explanation given if the individual’s agreement was not possible
I have seen this form or have discussed its contents and understand that the information will not be changed without my being
informed.
I agree / disagree (delete as appropriate) to this completed assessment being shared with others who may be involved in
delivering my care.
Signed:
Name:
If signed by a Representative, please give name and relationship and reason why they have signed
Relationship:
Date:
Reason:
London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
27/27