2005 - Nursing Intake Assessment Form by compliancedoctor

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This manual contains every policy and procedure you would need to have in order to obtain accreditation for ambulatory outpatient behavioral health businesses to include dual diagnosis, pysch disorders, drug detox, etoh detox. This manual has everything you need and is fully customizable to meet your individual facility needs.

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									                                      NURSING INTAKE ASSESSMENT

Name:                                                                                     Age:
Legal Status:                                     Date of Admission:                      Time:                  AM/PM
Precautions:       Suicidal     Homicidal          Fall Potential:        Yes      No
Allergies:
Occupation:                                                   Religion:
Marital Status:                               Children:      Yes         No        How Many?
Brought in by Whom:                                           From Where:
         How:          Ambulatory        Wheelchair          Gurney
Height:                 Weight:             BP:                    T:             P:                   R:
Patient’s Medical Health Aids:    Eyeglasses              Contact Lenses        Hearing Aid
                                  Dentures:     U  L                  Other:
Comments:
Chief Complaint and Date of Onset (Recent Losses):


Legal Issues/Court Dates:                                           Education Completed:
Family/Significant Others:

    Family Composition                    Relationship                   Significant Others       Relationship




                                                      MEDICATION PROFILE

Prescribed Medication:

            Name                              Route                            Dose               Last Taken




Herbal Supplements/Home Remedies/OTC Medications:

            Type                              Route                       Frequency/Dose          Last Taken




Street Drugs/Alcohol:

            Type                              Route                       Frequency/Dose          Last Taken




Prior Illnesses/Hospitalizations/Surgeries (approximate dates):
        Note:      Please refer any physical problem to patient’s physician.
NURSING INTAKE ASSESSMENT (continued)




Reference #2005 Partial Hospitalization   © Medical Consultants Network Inc. (800) 538-6264
NURSING INTAKE ASSESSMENT (continued)

Patient’s Strengths and Needs (please check):                        Skin:
                          None Poor Fair Good Excel.
Social Skills                               
Ability for Independence                    
Stability in Family                         
Stability in School/Work                    
Intellectual Ability                        
Verbal Skills                               
                                            
Ability for Insight
Involvement in Hobbies/                     
    Leisure Activities

The Following Items Were Completed:                                                              Indicate Locations of:
Orientation to program and staff                                        Yes           No
                                                                                                     Rashes:
Patient rights explained                                                Yes           No
Patient’s rights booklet given                                       
								
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