Communication (7 day) other language: Y/N RAP: Y/N

Mode of express: S/G/B Hearing/devices

Self Understood Understand others ENT_________

Imp./decline________________________________	Vision (7 day) RAP: Y/N

Glasses_____ Eye gtt.______

Last Screen______

Continence (14 day) Bladder __ Bowel__

Ostomy Catheter Appliance: Pads

Pattern Toileting Prog____

Imp/decline_______________________________ RAP: Y/N	Oral/dental (7 day) F P F P RAP: Y/N

Dentures: U L

Broken/loose tooth Last Screen_______
Health Condition (7 days)

fever edema SOB Vomiting

Unsteady gait Hallucinations

Pain/site (7 day) RAP: Y/N

Management Log: Y/N

F/U needed__________________________________	Falls (30 & 30-180 day) Injury: Y/N

Fx (30 & 30-180 day) RAP: Y/N

Infection/ABT (7 day UTI is 30 day)

F/U needed________________________________
Skin condition (7 day) Healed ulcer in past 90 D Y/N

Ulcers/stages/TX

Skin Sheet: Y/N

Skin Tx : T&R

F/U needed________________________________	Cr/Lotion

Supplement

Podiatry (90 day)
Medication (7 day) # of med. _____ New (90 d): Y/N

Med/Wound management

Enemas / irrigations

Types

F/S:

Injection	Sect G (7 day) Last PT/OT Screen____________

ROM: Neck Sh/Arms Hands Hips/knees Feet Bed mobility: Transfer Mode

Bathing Dressing Eating

Toileting Hygiene Locomotion________

Rail / Enable x 1 x 2 Amb Prog:___

Imp/decline______________________________ RAP: Y/N
Special TX / Procedure /Therapies (7 day)

SPL_____ OT_____ PT_____

Neb TX / Resp______ Psych_______

Nsg Rehab: Toilet / Walk / ROM / Splints RAP: Y/N

Intervent ( in environ to deal w/ beh /mood/cog: RAP: Y/N

Hospital/ER (90 day) ___________/___________

Physician visit/med change (14 day) ________/________

Labs (90 day)

F/U needed_________________________________	Special Tx in last 14 days

dialysis

IV med O2 I&O: Y / N

Monitoring

Ostomy: type______________ TX____________________ Suction

Transfusion

Palliative End of Life note: Y/N

Special Unit

Group/type ________ AIMS_________

Psych eval _______

F/U needed________________________________
Allergy / Dx:

Chart: Y/N MAR: Y/N TAR: Y/N CNA: Y/N Resident: Y/N Marks, a 12/03