Nursing Needs Assessment
PATIENT’S NAME
HOME ADDRESS
GP & ADDRESS
DOB
ICS / HOSPITAL
NUMBER / RECORD
NUMBER
CURRENT LOCATION
e.g. Ward, Care Home
ASSESSMENT
REQUESTED BY
REVIEW / NEW
PLACEMENT ARRANGED Y / N
NAME & ADDRES OF
NURSING HO,E
PLACEMENT
DATE OF ADMISSION /
TRANSFER TO
NURSING (CARE) HOME
DATE OF NURSING
NEEDS
ASSESSMENT(S) Date,
Signature & name of
Nurse Assessor & Place
of Work & Phone Number
DATE INITIAL RNCC
Date, Signature & name
of Nurse Assessor &
Place of Work & Phone
Number
DATE 3/12 REVIEW FOR
NEW PALCEMENT /
CRITERION 1, JOINT
FUNDING / FNC REVIEW
COMPLETED
Date, Signature & name
of Nurse Assessor &
Place of Work & Phone
Number
DATE OF COMPLETION
OR ANNUAL REVIEWS
Date, Signature & name
of Nurse Assessor &
Place of Work & Phone
Number
Primary Health Problem:
(is the patient clinically stable?)Care
Freq
Daily,
weekly,
mth,
24hr
Care By
Unqualified,
Qualified.
Supervised
(Circle all
that apply)
Review
Describe Changes Date / SignPrevious Medical History
Mobility / Bartel Score ( ) Ability / Restrictions?
Aids Used / crutches / hoist / transfer belt / turn table / sliding sheet / describe mobility &transferring / stairs / Manual Handling issues:
Q
S
U
Falls History; Tullamore Risk Assessment Socre ( )
Prevention / Action Implemented:Document Falls Risk – High / Medium / Low (circle)
Q
S
U
Breathing:
(Oxygen / supplied via / condenser / nebulisers / ownmachine?)
Q
S
U
Nutrition:
(Diet / swallow / PEG / Feeds self / Needs Help / All Meals / All drinks)Nutritional Screening Tool Score High / Medium / Low
Known to Dietician Y / N Referred to Dietician Y / N Date:
Q
S
U
Continence / Elimination:
(urinary / faecal / double / catheter urethral / supra pubic / ISC / stoma / aids to continence / proximity to facilities)If use pads document amount & appropriateness
No. Pads Day / Night ( )
Consider in depth continence assessment if appropriate
Q
S
U
Personal Hygiene:
(washing & dressing / self care / assistance / by 1/2 carers / bath aids)Care
Freq
Daily,
weekly,
mth,
24hr
Q
S
U
Review
Describe Changes Date / SignTissue Viability / Waterlow Score ( ):
(Tissue Viability Proforma included? Consider Weight / Nutrition / Mattress Hire / record step down options explored if patient requires Airwave mattress but does not trigger Tissue Viability proforma i.e. PA’s intact).Q
S
U
Skin Condition / Wounds / Dressings:
(Treatment / Type / chronic/ acute / trauma / frequency / by / reviewed)
Q
S
U
Communication / Sensory Deficit:
(memory / orientation / cognitive abilities / impairment / sight / hearing).Known to SALT Y / N Referred to SALT Y / N Date: Known to Stroke Coordinator Y / N
Referred to Stroke Coordinator Y / N Date:
Q
S
U
Sleep Pattern / Night Concerns:
(frequency / every night /occasionally / sedation / risk / level of Night care required / recent change in
sleep pattern)
Q
S
U
Overview of Mental Health:
(Joint CPN Assessment required for EMI placement / consider is separate mental health assessment needed?)6 CIT (Cognitive Impairment Test) Score ( )
Q
S
U
Emotional Well-Being
(consider loss of confidence, self-neglect, substance misuse, recent change in sleep pattern, short term memory loss,disorientation to place and time, recent bereavement)
Q
S
U
Specific Behavioural Issues
(consider agitation, history ofviolence/aggression to self/others / behaviour placing self or others at risk /
indicators of physical, emotional, sexual abuse, wandering / absconding)
Q
S
U
Specific Risk Assessment
(if not documented above): Include comments and plans to manage e.g. wandering / insight / anxiety / aggression / behaviour / mood management consider CPN / Learning Disability assessment. Identify specific risk factors and risk management planQ
S
U
Current Medication
(>4 medication per day consider link to falls, listdrugs & frequency, date of last medication review)
Q
S
U
Medication Management
(Administration / self medicating / patientsunderstanding / side effects / allergies / specific pain issues)
Q
S
U
Other Special Health Care Input / Supervision
State reason & intended care plan, (e.g. Speech & language / Macmillan / SALT / dietician /multidisciplinary / bloods / tests)
Q
S
U
Symptom Control
(Is there any evidence of unpredictable, hard tomanage, symptoms occurring?)
Q
S
U
Rehabilitation Needs:
(Potential / Options considered / delivered / complete. Multidisciplinary Assessment e.g. In / out patient therapy, residential rehab programme, community therapy)Care
Freq
Daily,
weekly,
mth,
24hr
Q
S
U
Review
Describe Changes Date / SignPrognosis:
(are there any significant conditions / issues which will affect prognosis?)Other Relevant Issues:
(not documented elsewhere)Carer Circumstances:
(consider need for carers assessment)Patients / Carers Views of the Proposed Care Plan:
Reason for Assessment:
(FNC review / new placement / change of status . going out of funds / criterion review / home care package)Specialist Continuing Care / Funded Nursing Care advice:
(Document Intermediate Care Coordinator / Continuing Care specialist assessor / FNC Coordinator discussed with, date & outcome)Specific Equipment
Needs. List all Items
(e.g. Commode provided by Nursing Home, does the patient need specialist equipment only usually available through hospitals or on prescription?)Summary of Continuing Care Assessment & Recommendations: Which Criterion is met?
Please circle which of the following Continuing Care Criterion 1, Joint Funding or None are indicated:• Criterion 1 (Please indicate all that apply a – d)
A B C D
• Joint Health & Social Care Package Recommended
• No Continuing Healthcare Criteria met
Recommendation & Rationale for Decision
(Please Explain)Any further information you wish to add, e.g. Criterion 2a the amount of health input service / fee to be paid above that funded by RNCC
RNCC banding: (Complete if recommending Nursing Home Placement, NB if you recommend a Nursing Home your patient will probably not be low band RNCC or you would have recommended a residential care home placement. (Self-funders can be the exception if they have chosen a Nursing Home but could be cared for elsewhere)
Signature of Assessor:
Name & Designation:
Date:
Contact Tel No:
Care Plan
NHS Support to Placement
Social Care Support to Placement
Care Home Category of Patient:
circle / delete as appropriateOP (Old Age)
DE (E) Service User over the age of 65 with dementia)
MD (E) Service User suffering from a mental disorder, excluding learning disability and dementia)
Provisional Discharge Date
(if appropriate):Provisional Discharge Location
(if known / appropriate):COPY OF NURSING NEEDS ASSESSMENT & RNCC BANDING TO BE GIVEN TO PATIENT FAMILY
ON DISCHARGE
Given To / Date: Given By:
