#GetP.First_Name# #GetP.Last_Name#, Resumption of Care

Fall Risk Assessment

Level of Consciousness

checked> 0 - Alert and oriented x 3 checked> 2 - Disoriented x 3 at all times checked> 4 - Intermittent confusion

History of Falls

checked> 0 - no falls checked> 2 - 1 to 2 falls checked> 4 - 3 or more falls

Ambulation Elimination

checked> 0 - Ambulatory and continent checked> 2 - Chairbound and requires assistance with toileting checked> 4 - Ambulatory and incontinent

Vision

checked> 0 - Adequate, with or without glasses checked> 2 - Poor, with or without glasses checked> 4 - Legally blind

Gait & Balance

checked> 0 - Normal, safe gait and balance checked> 2 - Minimal balance and/or ambulation deficits checked> 4 - Balance and ambulation deficits

Orthostatic Changes

checked> 0 - No noted drop in blood pressure between lying and standing. No change to cardiac rhythm. checked> 2 - Blood pressure drops less than 20mm between lying and standing. Increase of cardiac rhythm < 20. 20.">checked> 4 - Blood pressure drops greater than 20mm between lying and standing.Increase of cardiac rhythm >20.

Medications

checked> 0 - None of these medications taken currently or in past 7 days. checked> 2 - Takes 1 to 2 of these medications currently or in past 7 days. checked> 4 - Takes 3 to 4 of these medications currently or in past 7 days.

anesthetics,anthistamines,cathartics,diuretics, antihypertensive,antiseizure,benzodiazepines, hypoglycemics,psychotropics,sedative/hypnotics.

Medical History

checked> 0 - None present checked> 2 - 1 to 2 present checked> 4 - 3 or more present

Hypotension,vertigo,CVA,Parkinsons disease,loss of limb(s),seizures,arthritis,osteoporosis,fractures.

Equipment Issues

checked> 0 - No risk factors noted checked> 4 - Uses device inappropriately or does not use recommended device

Total Score = #FallRate# HIGH RISK for Falls Total Score = #FallRate# LOW RISK for Falls

Parameters for Physician Notification

Vital 1

less than

greater than

Vital 2

less than

greater than

Vital 3

less than

greater than

Vital4

less than

greater than

Vital 5

less than

greater than

Vital 6

less than

greater than

Vital 7

less than

greater than

Vital

Add Vital

Wounds

Add

Wound Type

Abrasion Bite Burn Contusion Diabetic Ulcer Graft Gunshot Laceration Nodule

Pressure Ulcer Puncture Skin Tear Stab Stasis Ulcer Surgical Wound Welt Other

If pressure ulcer stage

Status

Length

Width

Depth

Surrounding Tissues

clean scabbed crusted indurated gaping blistered separated bruised

Characteriscts

clean crusted gaping separated scabbed indurated blistered bruised cynanotic eschar excoriated Flaking hard necrotic reddened rough weeping sloughing green

dry cracked muschy soft loose --SHAPE-- straight circular irregular oblong rectangle square drainage no drainage block brown clear gray moist

pink red reddish purple serosanguineous serous tan yellow white haemoserous --AMOUNT-- scant minimal moderate copious --ODOR-- foul odor no odor Other..

Location

Notes

Diagnosis Select

*SEVERITY KEY

0 - Asymptomatic, no treatment needed

1 - Symptoms well controlled

2 - Symptoms controlled with difficulty

3 - Symptoms poorly controlled

4 - history of rehospitalizations

Severity level?

0 1 2 3 4

Primary?

Yes No

Secondary?

Yes No

Onset or Exacerbation

(O) (E)

Add Case Mix For ICD10 Z-Code

Diagnosis Search

Add Manifestation For ICD10 Z-Code

Manifestation Diagnosis Search

If this is a ICD10 Z-Code, and you want to add a case mix diagnosis, click "add case mix..."now to include that data. Click "add manifestation" to add a manifestation code.

Pain Assessment

Pain Level

checked /> No Pain checked /> pain level 0 (low) checked /> pain level 1 (low) checked /> pain level 2 (low) checked /> pain level 3 (med) checked /> pain level 4 (med) checked /> pain level 5 (med)

checked /> pain level 6 (med) checked /> pain level 7 (high) checked /> pain level 8 (high) checked /> pain level 9 (high) checked /> pain level 10 (high)


0	2	4	6	8	10

Pain assessment incomplete

Pain Characteristics

checked /> Throbbing checked /> Stabbing checked /> Sharp checked /> Aching checked /> Burning

checked /> Numb checked /> Shooting checked/> Not Applicable checked/> Other

Pain threshold

checked/> at rest checked/> with minimal activity checked/> with moderate activity checked/> with strenuous activity checked/> Not Applicable

Rate Current pain treatment effectiveness on a scale* of 1 to 10 (1=low effectiveness)

checked/> 1 checked/> 2 checked/> 3 checked/> 4 checked/> 5

checked/> 6 checked/> 7 checked/> 8 checked/> 9 checked/> 10

How long does each treatment work before needing another dose

checked/> 30 minutes checked/> 1 hour checked/> 2 hours checked/> 3 hours checked/> 4 hours checked/> 6 hours

checked/> 12 hours checked/> 24 hours checked/> more than 24 hours checked/> Not Applicable checked/> Other

Whats is patient's opinion of the cause of her/his pain?

checked/> physical activity checked/> disease process checked/> Not Applicable checked/> Other...

Add vital

Type

Temperature Heart Rate Respiratory Rate Blood Pressure Systolic Blood Pressure Diastolic Weight Height Pain (scale 1-10) Abdominal Girth Head Circumference O2 Saturation

Severity

0 asymptomatic 1 well-controlled 2 controlled with difficulty 3 poorly controlled 4 hx hospitalizations

Reading

Notes

Braden Scale For Predicting Pressure Sore Risk

SENSORY PERCEPTION ability to respond meaningfully to pressure-related discomfort

checked> 1. Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation OR limited ability to feel pain over most of body checked> 2. Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment which limits the ability to feel pain or discomfort over 2 of body. checked> 3. Responds to verbal commands, but cannot always communicate discomfort or the need to be turned OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. checked> 4. Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.

MOISTURE degree to which skin is exposed to moisture

checked> 1. Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. checked> 2. Skin is often, but not always moist. Linen must be changed at least once a shift. checked> 3. Skin is occasionally moist, requiring an extra linen change approximately once a day. checked> 4. Skin is usually dry, linen only requires changing at routine intervals.

ACTIVITY degree of physical activity

checked> 1. Confined to bed. checked> 2. Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. checked> 3. Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair checked> 4. Walks outside room at least twice a day and inside room at least once every two hours during waking hours

MOBILITY ability to change and control body position

checked> 1. Does not make even slight changes in body or extremity position without assistance checked> 2. Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. checked> 3. Makes frequent though slight changes in body or extremity position independently. checked> 4. Makes major and frequent changes in position without assistance.

NUTRITION usual food intake pattern

checked> 1. Never eats a complete meal. Rarely eats more than a of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR is NPO. checked> 2. Rarely eats a complete meal and generally eats only about 2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. checked> 3. Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN. checked> 4. Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals.

FRICTION & SHEAR

checked> 1. Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. checked> 2. Problem Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time. checked> 3. Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.

Total Score = #PressureRate# LOW RISK for Pressure Ulcers MODERATE RISK for Pressure Ulcers HIGH RISK for Pressure Ulcers

1 - 12 =HIGH RISK

13 - 14 =MODERATE RISK

15 - 23 =LOW RISK