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					NHS No Family Name

Date of Birth 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 o o   Culturally sensitive User centred Equitable





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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.

 

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London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
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NHS No Family Name
Date of Commencement of Assessment:

Date of Birth Forename

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 Name: Contact Details

Current Address (if not permanent address):

Is English the individual’s first language?

Yes

No

If not what is the first language?

Has the individual, main carer or advocate been given written information about the Continuing Healthcare process? Has the Continuing Healthcare process been explained to the individual, main carer or advocate? Was the individual involved in the completion of the Health Needs Assessment?

Yes Yes Yes

No No No

Was the individual offered the opportunity to have a representative such as a family member or other advocate present when the Health Needs Assessment was completed? If yes, did the representative attend the completion of the Health Needs Assessment? Name : Address: Please give the contact details of the representative

Yes

No

Yes

No

Telephone No: Relationship to patient:

London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
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NHS No Family Name

Date of Birth 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? Tick one box only (2) Which age group applies to you? Tick one box only Male 0-15 55-64 Female 16-24 65-74 Transgender 25-34 75-84 35-44 85+ 45-54

(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 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 Yes No

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

(4) What is your ethnic group? Tick one box only

C – Asian, or Asian British Indian Pakistani Bangladeshi below

Any other Asian background, write

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, Catholic, Protestant and all other Christian denominations

None

Christian

Buddhist

Hindu

Jewish

Muslim

Sikh

(6) Which of the following best describes your sexual orientation? Tick one box only

Heterosexual/Straight Lesbian/Gay Woman Gay Man Bisexual Prefer not to answer Other, write below

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NHS No Family Name

Date of Birth 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? Lasting PoA: Deputy: Enduring PoA: Additional Info: Advanced decision to refuse treatment? Located where? Has this person got capacity? If Yes - has their consent been obtained for this assessment? Have they given consent to have information shared with their next of kin, main carer or advocate? Has their consent been obtained for sharing information contained within this assessment with 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? Yes Yes Yes No No No Yes No Date decision made: Self Other (as below) Date decision made: Level of power: Level of power: Health/welfare Financial Health/welfare Financial

Yes

No

SIGNATURE OF ASSESSED PERSON: SIGNATURE OF ASSESSED PERSON’S REPRESENTATIVE: ASSESSOR: SIGNATURE: DESIGNATION: DATE:

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NHS No Family Name

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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: SIGNATURE:

DESIGNATION: DATE:

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NHS No Family Name

Date of Birth 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: SIGNATURE: DESIGNATION: DATE:

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NHS No Family Name

Date of Birth 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: SIGNATURE:

DESIGNATION: DATE:

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NHS No Family Name

Date of Birth 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: SIGNATURE:

DESIGNATION: DATE:

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NHS No Family Name

Date of Birth 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 display: Disinhibition Persistent noisiness Persistent restlessness Resistance to care Interference with others Inappropriate sexual behaviour Inappropriate urination Faecal Smearing At night, does the person display: Restlessness Wandering Need for sedation Has the person been physically violent? Do they threaten violence? Are they verbally abusive? Daily Daily Daily Daily Daily Daily Daily Daily At least weekly At least weekly At least weekly At least weekly At least weekly At least weekly At least weekly At least weekly Less than weekly/infrequently Less than weekly/infrequently Less than weekly/infrequently Less than weekly/infrequently Less than weekly/infrequently Less than weekly/infrequently Less than weekly/infrequently Less than weekly/infrequently Never Never Never Never Never Never Never Never

Sources of information:

Daily Daily Daily Daily Daily Daily

At least weekly At least weekly At least weekly At least weekly At least weekly At least weekly

Less than weekly/infrequently Less than weekly/infrequently Less than weekly/infrequently Less than weekly/infrequently Less than weekly/infrequently Less than weekly/infrequently Details :

Never Never Never Never Never Never

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: SIGNATURE: DESIGNATION: DATE:

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NHS No Family Name

Date of Birth 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 Disorientated in place Disorientated to person Confused Always Always Always Always Mostly Mostly Mostly Mostly Occasionally Occasionally Occasionally Occasionally Infrequently Infrequently Infrequently Infrequently Never Never Never 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 functioning

Yes

No

Other sources of information: Has an Abbreviated Mental Test, Mini Mental State Examination or other validated test been carried out? If not please arrange for one to be done before proceeding with this assessment Score: Date test completed: Completed by? Name: Designation:

ASSESSOR: SIGNATURE:

DESIGNATION: DATE:

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NHS No Family Name

Date of Birth Forename

MINI MENTAL STATE EXAMINATION Score (
1. Orientation What is the year? What is the date? What is the month? Where are we? Country? Town? Floor? ( ( ( ( ( ( /1) /1) /1) /1) /1) /1)

/30)
Season? Day? ( ( /1) /1)

2.

County? Hospital?

( (

/1) /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. Attention & Calculation Serial sevens. Give one point for each correct answer. Stop after five answers (Alternative: spell WORLD backwards). Recall Ask for names of three objects learned in Question 3 (above) Give one point for each correct answer Language Point to a pencil and a watch. Have the person name them as you point Have the person repeat “No ifs, ands or buts” 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”. Ask the person to read and obey the following: “Close your eyes” Ask the person to write a sentence of his or her own choice (sentence should contain a subject, object & make sense. Ignore spelling) 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 quadrangle

(

/3)

4.

(

/5)

5.

(

/3)

6.

( (

/2) /1)

7. 8.

( (

/3) /1)

9 10.

(

/1)

11.

(

/1)

ASSESSOR: SIGNATURE:

DESIGNATION: DATE:

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NHS No Family Name

Date of Birth 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 Depressed Distressed Does the person: Respond to pleasant events Have episodes of sadness

Always Always Always

Mostly Mostly Mostly

Occasionally Occasionally Occasionally

Infrequently Infrequently Infrequently

Never Never Never

Always Always

Mostly Mostly

Occasionally Occasionally

Infrequently Infrequently

Never Never

Describe below any interventions used (medication or therapy) and the individual’s ability to participate in their care plan.

What is the individual’s insight into their care needs/illness?

Does the individual know he/she needs help? Yes No

Please comment on your professional view of the individual‟s insight

Other sources of information: Has the person had a specialist psychological assessment? Yes No (If yes, provide evidence below)

Has a Geriatric Depression Scale, 'Cornell Scale’ for assessing depression in people with dementia or other validated test been completed? ASSESSOR: SIGNATURE:

If yes - what was the score? Yes No Date of test: Which Test completed? DESIGNATION: DATE:

London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
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NHS No Family Name

Date of Birth 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. 2. 3. 4. 5. 6. 7. 8. 9. Are you basically satisfied with your life? Have you dropped many of your activities and interests? Do you feel that your life is empty? Do you often get bored? Are you in good spirits most of the time? Are you afraid that something bad is going to happen to you? Do you feel happy most of the time? Do you often feel helpless? Do you prefer to stay at home, rather than going out and doing new things? Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No

10. Do you feel you have more problems with memory than most? 11. Do you think it is wonderful to be alive now? 12. Do you feel pretty worthless the way you are now? 13. Do you feel full of energy? 14. Do you feel that your situation is hopeless? 15. Do you think that most people are better off than you are?

Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No

TOTAL SCORE: Score 1 point for each italicised answer. A total score of 6 – 15 suggests depression.

ASSESSOR: SIGNATURE:

DESIGNATION: DATE:

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NHS No Family Name

Date of Birth Forename

The Cornell Scale for Depression
Alternative scale for persons who are unable to participate in the Geriatric Depression Scale SCORE Ratings should be given based on signs and symptoms occurring during the week prior to interview. No score a 0 1 should be given in symptoms resulting from physical Unable to Absent Mild or 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 2 Severe

TOTAL SCORE:
ASSESSOR: SIGNATURE: DESIGNATION: DATE:

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NHS No Family Name

Date of Birth 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 Able to understand instructions Able to make needs known (orally) Able to make needs known (non-orally) Always Always Always Always Mostly Mostly Mostly Mostly Occasionally Occasionally Occasionally Occasionally Infrequently/Never Infrequently/Never Infrequently/Never Infrequently/Never

If you answer yes to the questions below please give comments: Does the person have a hearing impairment?

Yes

No

Does the person have a visual impairment? ASSESSOR: SIGNATURE:

Yes

No

DESIGNATION: DATE:

London Health Needs Assessment V6 080909 to be reviewed by 31/03/10
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NHS No Family Name

Date of Birth 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 balance? Does the person use a wheelchair? Can the person walk? Can the person climb stairs? Can the person get in and out of bed? Can the person get on and off a chair? Can the person get on and off the toilet? Does the person require positioning in bed? Please comment on the person’s upper limb function Does the person have a complex sitting position? Yes No Assisted Can the person weight bear? Yes No Assisted

Yes No (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 With assistance of 1 With assistance of 2 Unable/NA Independently With the use of aids, if yes – please specify in comments box below With assistance of 1 With assistance of 2 Unable/NA Independently With the use of aids, if yes – please specify in comments box below With assistance of 1 With assistance of 2 Unable/NA Independently With the use of aids, if yes – please specify in comments box below With assistance of 1 With assistance of 2 Unable/NA Independently With the use of aids, if yes – please specify in comments box below With assistance of 1 With assistance of 2 Unable/NA Independently With the use of aids, if yes – please specify in comments box below With assistance of 1 With assistance of 2 Unable/NA

Yes

No Please include the physio / OT assessment for any specialist aids Has it been provided?

Type of mobility aid used If the person requires mobility equipment, specify the type and for what purpose

Mobility Prognosis Has the person fallen?

Likely to improve

Stable

Deteriorating

Yes No (If yes detail the history of falls below, indicating when falls occurred, how 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? ASSESSOR: SIGNATURE:

Yes

No

Reason if not attached? DESIGNATION: DATE:

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NHS No Family Name

Date of Birth 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 themselves? What consistency of food is required? Yes Normal Needs food cutting up Pureed Soft Needs supervision/prompting Mixed Needs feeding

If yes, is this: Does the person require feeding aids? PEG Yes No TPN Jejunostomy Other, please specify: NG (If NG will it be removed before discharge? Yes No)

(State in the comments box if this requires skilled assessment and review) Can the person drink independently? What consistency of fluids is required? Has there been recent weight gain/loss? Yes Normal Yes No Needs supervision/prompting Thickened Needs assistance Yes No (If yes detail the management plan in the comments box)

Is the person at risk of choking whilst eating/drinking?

Not Known (If yes detail the weight change and time period below) Height at time of assessment? Yes BMI at time of assessment?

Weight at time of assessment? Has a Malnutrition Universal Screening Tool (MUST) been completed? Score: ASSESSOR: SIGNATURE: Date:

No (If yes, complete box below)

Name and designation of assessor: DESIGNATION: DATE:

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NHS No Family Name

Date of Birth Forename

MUST (Malnutrition Universal Screening Tool)
Weight Previous recorded weight Measurement BMI Unintentional weight loss in 3-6 months Acute Disease Effect Height Date previous weight recorded Scores (please score as indicated) >20.0 = 0 18.5 – 20.0 = 1 <18.5 = 2 <5% = 0 5 – 10% = 1 >10% = 2 Kg Kg m Score

kg/m2 kg

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: SIGNATURE: DESIGNATION: 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) Ulna 32 31.5 31 30.5 30 29.5 29 28.5 28 27.5 27 26.5 26 25.5 25 24.5 24 23.5 23 22.5 22 21.5 21 20.5 length Men 1.87 1.86 1.84 1.82 1.81 1.79 1.78 1.76 1.75 1.73 1.71 1.7 1.68 1.67 1.65 1.63 1.62 1.6 1.59 1.57 1.56 1.54 1.52 1.51 (>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) Ulna 32 31.5 31 30.5 30 29.5 29 28.5 28 27.5 27 26.5 26 25.5 25 24.5 24 23.5 23 22.5 22 21.5 21 20.5 length Women 1.84 1.83 1.81 1.79 1.78 1.76 1.75 1.73 1.71 1.7 1.68 1.66 1.65 1.63 1.61 1.6 1.58 1.56 1.55 1.53 1.52 1.5 1.48 1.47 (>65)

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NHS No Family Name

Date of Birth 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? Yes No Supra pubic Urethral Other? Is the person able to self catheterise?

Yes

No No

Does the person have a Stoma/ Urostomy? Yes No

Does the person suffer from chronic UTIs? Yes (Please give history below) When did the UTI occur

What treatment was required (include 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: SIGNATURE: DESIGNATION: DATE:

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NHS No Family Name

Date of Birth 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 wounds? Yes No

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 integrity If yes detail here:

Yes

No

Does the person require positioning/turning? If yes how often? Does the person have a diagnosed skin condition? (If yes, detail condition and management plan below) Has a Waterlow, Walsall or other validated test been completed? Score: ASSESSOR: SIGNATURE: Date:

Yes

No

Yes

No

Yes No (If yes, complete boxes below) Name and designation of assessor: DESIGNATION: DATE:

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Date of Birth Forename

WATERLOW RISK ASSESSMENT TOOL
Ring scores in table and total. Several scores per category can be used
BUILD/WEIGHT FOR HEIGHT Average Above average Obese Below average 0 1 2 3 SKIN TYPE (visual risk areas) Healthy Tissue paper Dry Oedematous Clammy (temp) Discoloured Broken/spot CONTINENCE Complete/ catheterised Occasional incontinence 0 MOBILITY Fully 0 SEX AGE 0 1 1 1 1 2 3 Male Female 14 - 49 50 – 64 65 – 74 75 – 80 81+ APPETITE Average or stable on PEG feed Poor 0 1 2 1 2 3 4 5
NEUROLOGICAL DEFICIT SPECIAL RISKS

e.g. Terminal cachexia Cardiac failure Peripheral vascular disease Anaemia Smoking

8 5 5 2 1

e.g.

1

Restless/ Fidgety

1

1

Diabetes, MS, CVA, Motor/sensory paraplegia

4 6

Catheterised/ incontinent of faeces Doubly incontinent

2

Apathetic

2

Very poor

2

3

Restricted Inert/traction

3 4

NBM/ anorexic

3

MEDICATION

Cytotoxics High dose steroids Antiinflammatory

4

Chairbound SCORE:

5

10+AT RISK, 15+ HIGH RISK, 20+ VERY HIGH RISK

ASSESSOR: SIGNATURE:

DESIGNATION: DATE:

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Date of Birth Forename

BREATHING
CLINICAL PICTURE What is the respiratory condition? Pulse Respiratory Rate SaO2 at rest SaO2 on exertion Temp Shortness of breath frequently each day BP Drowsiness Ankle Oedema Cyanosis Clubbing Daily At least Weekly Yes Yes Yes Yes No No No No Never Smoker ? Yes No

Less than Weekly/ Infrequently

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 Wheeze Sputum retention Chest Pain Nocturnal Breathlessness Anxiety Hypoxia Exacerbation of COPD Recurrent Chest Infection Daily At least Weekly Daily At least Weekly Daily At least Weekly Daily At least Weekly Daily At least Weekly Daily At least Weekly Daily At least Weekly State Frequency: less than Weekly /Infrequently less than Weekly /Infrequently less than Weekly /Infrequently less than Weekly /Infrequently less than Weekly /Infrequently less than Weekly /Infrequently less than Weekly /Infrequently Never Never Never Never Never Never Never

State Frequency: Respond to treatment? Please comment:

Management Plan Pleural Effusion Self Management Nebuliser Prescription of antibiotics and/or steroids Airway clearance techniques required Provision of home oxygen BiPAP CPAP Tracheotomy Provision of home ventilation ( please state if Invasive or non invasive) ASSESSOR: SIGNATURE: Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No DESIGNATION: DATE: Please provide detail on management plan: including type of intervention required, frequency and Intensity:

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Date of Birth 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? What is the person’s condition with regard to their medication regime? What is the review date for the medication? Is further specialist assessment indicated? Is the person: In need of Carer Able to self medicate What level of supervision is required? In need of Trained Nurse: Administration Monitoring Supervision Administration Yes No Always Stable Mostly Unstable Occasionally Infrequently/Never

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: SIGNATURE:

DESIGNATION: DATE:

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Date of Birth 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, define the location and extent of pain on the pain map below) Yes No

Comments:

Sources of information:

Does the person experience breakthrough pain? Are any PRN drugs in use? Yes No Frequency?

Yes Type?

No

Are there any other symptoms to control? e.g. Nausea; Fatigue – please describe below

Has a Numeric Graphic Rating Scale, Abbey Pain Scale, Pain Thermometer or other validated test been completed? Name and designation of assessor ASSESSOR: SIGNATURE:

No Yes If yes please attach

Score (& test):

Date:

DESIGNATION: DATE:

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Date of Birth 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): Sources of information: Brain Injury 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: SIGNATURE:

DESIGNATION: DATE:

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NHS No Family Name

Date of Birth 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 BLADDER

0 = Incontinent 0 = incontinent or catheterised & unable to manage 0 = Needs help 0 = dependent

GROOMING TOILET USE

1 = Occasional incontinence 1 = occasional accident (Maximum x 1 per 24 hours) 1 = Independent (with face/ hair/ teeth/ shaving) 1 = needs some help , but can do something

2 = continence 2 = continence (for over 7 days)

FEEDING

TRANSFER

MOBILITY

DRESSING STAIRS BATHING TOTAL SCORE /20

1 = needs help (with cutting, spreading butter etc) 0 = immobile 1 = major help (1-2 people, physical) 2 = minor help (verbal or 3 = independent physical) 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) 0 = dependent 1 = needs help (verbal, 2 = independent physical, carry aid) 0 = unable 1 = needs help (verbal, 2 = independent up and physical, carry down) down 0 = dependent 1 = independent

0 = unable

2 = independent (on, off, dressing & wiping) 2 = independent

ASSESSOR: SIGNATURE:

DESIGNATION: DATE:

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NHS No Family Name

Date of Birth 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:

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