Documents / Notes / Care Plan Date Yes /No Comment

1 Register Complete up to date

2 Next of Kin details complete and up to date

3 Doctor's Notes complete and up to date

4 Medication Kardex completed and up to date

5 Personal Profile details complete and up to date

6 Comprehensive ADL assessment complete and up to date
7 Screening Page complete and up to date
8 ADL Map Page complete and up to date
9 Care Plan complete and up to date

Activities of Daily Living Date Yes /No Comment

1 Communication needs up to date
2 Controlling Body Temp needs up to date
3 Safe Environment details up to date
Fall risk assessment complete and up to date
4 Mobility needs up to date
Manual Handling assessment complete and up to date
5 Personal Care needs up to date
Barthel assessment complete and up to date
5 Skin Integrity assessment up to date
Waterlow Assessment complete and up to date
Skin assessment complete and up to date (if required)
Wound assessment and up to date (if required)
6 Pain (if indicated)
Pain assessment complete and up to date (if required)
7 Breathing & Circulation needs up to date
8 Nutrition Status up to date
Dietary needs and assessment complete and up to date
9 Elimination details up to date
10 Self Image details up to date
11 Recreational & Social details up to date
12 Rest & Sleep details up to date
13 Dying & Spirituality details up to date
14 Other, if indicated and include, complete and up to date
Data collection taken by:
Date of Data colection:
 Assessment Date

ADL Signature of Assessing Nurse

1 Communication
SPEECH
1. Normal Function

2. Dysarthria / Dysphasia
3. Loss of ability due to Cognitive Dysfunction

HEARING
1. Normal Function
2. Hearing Impairment, Use of hearing aid NA / N / Y (specify)
3. Deaf

VISION
1. Normal
2. Impaired, Use of Spectacles NA / N / Y, (specify)
3. Blind

EMOTIONAL STATE
1. Alert
2. Orientated
3. Confused
4. Anxious
5. Apathetic / Depressed
6. Agitated
7. Content
8. Challenging Behaviour

COGNITIVE STATUS
1. Mini mental test score MMSE (if indicated)
2. Depression score (if indicated)
3. Other relevant details: known to CPN, Old Age Psyhchiatry

Care Plan N / Y
 Assessment Date

ADL Signature of Assessing Nurse

2 Controlling Body Temp
1. Independent
2. Assisted

Care Plan N / Y
3 Safe Environment
1. Independent
2. Assisted
3. Risk of Fall; , see Fall Risk Assessment CANNARD
3-8 Low risk; 9-12 Medium risk; 12+ High risk

Care Plan N / Y
4 Mobility; see Manual Handling Assessment chart
1. Independent
2. Assisted
2a. Walking, 2b. Transfer, 2c. In / Out Bed, 2d. Aids used, specify
3. Chair / Bedfast,

4. Hoist, see Manual Handling Assessment chart

Physio / Physical therapy referral NA /N / Y

Care Plan N / Y
5 Personal Care & Skin Integrity
Barthel; Independent, Low, Medium, High, Maximum
Waterlow; 10+ At Risk; 15+ High Risk; 20+ Very High Risk
PAC AID -Specify, e.eg Mattress, Cushions, Turn Chart etc
Hygiene & Dressing
1. Independent
2. Assisted
Skin Integrity, complete Skin Assessment if indicated
1. Skin Integrity; Intact Yes / No. If NO see Skin Assessment
2. Dry ; 3. Red;
4. Wound(s), Pressure Ulcers, Surgical, Other
Wound Assessment Y / N
Treatment Plan, See Care Plan

Care Plan N / Y
 Assessment Date

ADL Signature of Assessing Nurse

6 Presence of Chronic Pain
1. No Pain
2. Moderate Pain

3. Severe Pain
If Chronic Pain identified specify as follows
Site
Duration
Effect on daily life
Treatment & Management, e.g. Analgesic, Positional, Massage
Pain Scale Assesssment completed N / Y

Care Plan N / Y
7 Breathing & Circulation
PMH of Cardiac, Respirarory or Circulatory Disease

Respirations RPM
Base line O2 Sats
Blood Pressure BP

Pulse BPM

Colour, Palour, Breathing Pattern

Use of ; inhaler-(specify); O2; nebs; etc

Positioning

(Ex) Smoker N / Y

Resident informed of Smoking Policy NA / N / Y

Care Plan N / Y
 Assessment Date

ADL Signature of Assessing Nurse

8 Nutrition Status
Height (mts)
Weight (kgs)
BMI
MUST
1. Usual diet & appetite etc.

2. Any recent weight loss or gain N / Y

MUST Assessment if indicated
3. Likes & Dislikes
Likes

Dislikes

4. Special diet, specify

Care Plan N / Y
9 Elimination
A. Urinary
1. Voiding normally
2. Incontinent of urine N /Y, e.g, stress, occasional, continous
3. Daytime N / Y
4. Nightime N / Y
5. Assessment required NA / N / Y
5.a. Assessment completed and submitted to HSE, Date
6. Incontinence aids used specify
7. Catheter, size ____ type _____ site ______
8.. Date last changed
B. Bowel Pattern
1. Continent
2. Incontinent
3. Frequency of motions
4. Prone to constipation
5. Normal Bristol Score Stool
6. Any known bowel diorders e.g. Diverticular, haemorroids
C. History of apperient use
Specify

Care Plan N / Y
 Assessment Date
ADL
Signature of Assessing Nurse
10 Self Image
Detail relevant information regarding
Resident's sense of self
Preferred style in dress

Care Plan N / Y
11 Recreational & Social
Previous / Present Occupation

Hobbies / Interests

Family Involvement

Social interaction with family & staff

Preferred activities e.g. outings, Sonas etc.

Activity program plan

Care Plan N / Y
12 Rest & Sleep
Normal sleeping pattern
Likes to go to bed at
Likes to get up at
Daytime rest N / Y

Aids to sleep
Chemical / Environmental / Alternative
Specify:

Care Plan N / Y
13 Spirituality & Dying
Personal Beliefs
Religion (specify if resident wishes)

Pastoral care needs & wishes

Fears and wishes of resident & family

Expectation of resident and family with regard to LTC

Care Plan N / Y
 Assessment Date

ADL Signature of Assessing Nurse

Other Relevant Information
ADL Care Plan Map for Activities of Living CP Number
Circle current status as assessed
1 Communication
1. Speech, 2. Hearing, 3. Vision, 4. Emotional, 5. Cognitive.
2 Controlling Body Temp
1. Independent, 2. Assisted
3 Safe Environment
1. Independent 2. Assisted
Risk of Fall; LOW, MEDIUM, HIGH
4 Mobility
1. Independent, 2. Assisted
Manual Handling Assessment & Guidelines
5 Personal Care & Skin Integrity
Barthel; Independent, Low, Medium, High, Maximum dependency
Waterlow; 10+ At Risk; 15+ High Risk; 20+ Very High Risk
Skin Integrity, Intact Y / N Wound assessment Y/N
6 Pain, if indicated

7 Breathing & Circulation

Blood Pressure BP
Pulse BPM O2 Sats
Respirations RPM Smoker Y / N
8 Nutrition Status
Weight Kgs BMI
Height Mts MUST
9 Elimination
Urinary function
Bowel function Apperients Y / N
10 Self Image

11 Recreational & Social

Activity Plan
Hobbies / Interests
12 Rest & Sleep
Pattern / Aids, Chemical, Environmental, Alternate
13 Spirituality & Dying
Sacrament of the sick Y / N
14 Other: (specify)

RN signature
Resident / Representative signature:
Date
Any other comments:
Register Personal Details
Number
Surname
First Name
Date of Birth
Previous Address

Nationality
Occupation (previous)
Marital Status
Religion (if disclosed)

PPS No:
GMS No:

Ward of Court N / Y
YES - Details

Next of Kin contact details

Name
Relationship
Address

Contact No(s):

GP Name
GP address

GP phone & fax No:

MDT involved in care e.g. Psychiatrist, OT, Physio / Physical Therapist, Dietician etc.

Social & Care Summary

Medical History Summary

Known Allergies:
 Activities of Living
1 Communication
1. Speech
2. Hearing
3. Vision
4. Emotional State
5. Cognitive Status

2 Controlling Body Temp

1. Independent
2. Assisted
3. Current Temperature

3 Safe Environment
1. Independent
2. Assisted
3. Risk of Falls; CANNARD Low, Medium, High

4 Mobility
1. Independent
2. Assisted
3. Chair / Bedfast
4. Hoist or other Aids, specify

5 Personal Care & Skin Integrity

Barthel; Independent, Low, Medium, High, Maximum dependency
Waterlow; 10+ At Risk; 15+ High Risk; 20+ Very High Risk
Skin Integrity; Intact Y / N
If No, specify; Wound(s), Pressure Ulcer, Surgical, Other
Current Treatment:

6 Pain, presence of (if indicated)

Site & Severity:
Effect on daily living
Treatment & Management

7 Breathing & Circulation

Blood Pressure BP
Pulse BPM O2 Sats
Respirations RPM Smoker N / Y

PMH of Cardiac or Respiratory disease

8 Nutrition Status
Weight Kgs BMI
Height Mts MUST Score

Likes and Dislikes

Likes

Dislikes

Special Diet, specify

9 Elimination
Urinary function Continent Y / N
PMH of bladder disorder e.g. prostate problems, UTI's

Bowel function
Normal Bristol Score Stool Apperients N / Y, specify:
Frequency of motions Continent Y / N
PMH of bowel disorder,e.g. diverticular, haemorrhoids, IBS, constipation

10 Self Image
Summary

11 Recreational & Social

Hobbies / Interest
Family involvement
Social interaction with family & staff
Preferred activities e.g outings, reading, Sonas etc.

12 Rest & Sleep

Normal sleeping pattern
Daytime rest N / Y

Aids to sleep
Chemical / Environmental / Alternative
Specify:

13 Spirituality & Dying

Personal beliefs, Religion (if resident wishes to disclose)

Pastoral needs & care

Wishes and fears of resident & family

Expectation of resident, NOK & family

Sacrament of the sick N / Y, Date

 Other relevant information

NOK notified of Transfer N / Y

Reason for Transfer

Date & Time

Notes /Comments

RN Signature