South Devon Care Services Pre-Assessment Form

Thank you for taking the time to fill in this form. Please note that you can't save your progress, so please ensure you have all the information to answer these questions before you start

If you have any queries about this form of your care, please contact Sheena Parker on 07704 573281 or email sheena.parker@southdevoncareservices.com

Name

Assessment Information

Section 1

Person managing admission / case manager

Place of assessment

People present

Other sources of information used to make assessment

About the person being assessed

Section 2

Likes to be called

NHS Number

NI Number

Hospital number

Date of Birth

Marital status

Religion

Address (including Postcode)

Place from which admission will take place Home/Other (please state)

Reason for admission to a care home

Next of kin details

Section 3

Next of Kin Name

Relationship

Address (including postcode)

Telephone Number

Mobile Number

Referral details

Section 4

Name

Designation

Address (including postcode)

Tel No.

General practitioner details

Section 5

GP Name

Surgery name, address and postcode

Surgery email

Surgery telephone number

Will a change of doctor/GP be required?

Dentist details

Section 6

Do they have a Dentist

Dentist Name

Skip if no Dentist

Practice name, address and postcode

Skip if no Dentist

Practice email

Skip if no Dentist

Practice telephone number

Skip if no Dentist

Medical information

Section 7

Medical health history including surgery/any infections: MRSA/C-DIFF/Scabies/other

Details of medical/Health/Specialist diagnose that will require health promotion care plan

Any allergies?

Mental Health

Please give full details e.g. Psychiatric history: Depression, Suicidal. Cognition, Confusion, Orientation. Physical/Verbal aggression. Motivation. Sundowning. Memory/ Confusion. Behaviour. Delusions. Hallucinations. Clinical anxiety. Antisocial behaviours / mood.

Details of ongoing screening or health checks or health promotion

e.g. Blood Pressure, Phosphorus & Blood tests, Pacemaker. Glaucoma, vision. Hearing. Thyroid. Renal. Diabetes. CVA. Depression. Dementia. Pain. Mobility. Progressive illness. Outstanding appointments. Other

Is a TEP form (Treatment escalation plan) in place?

Emergency requirements/preferences

e.g. Ill health. Minor injury. Major injury / illness – preferences: Hospitalisation / A & E. Who will attend / escort: Key people and contacts. Escort to scheduled appointments. Specialist assistance / support needed.

Current medication

Medication comments

Compliance

Concerns if any

Administration method

Self/syringe/spoon

Living will / advance directives?

In the event of death are any specific arrangements in place?

Advocacy arrangements

Section 8

Do they have the ability to state their own preference?

Please add details for any of the above

If yes, by whom

Is this person giving permission for information about themselves to be passed onto others?

Do they only have non-verbal communication?

Are they able to communicate in writing?

Are they coherent?

Do they have any issues with memory?

Is this person able to make medical/clinical decisions in their own best interest?

Are any of the following in place to guide decision making? Enduring

Enduring Power of Attorney / Living will / Advanced Care Plan.
Please state which.
We will need a copy of these for our files

Are there any care practices restricting this person’s freedoms?

Is a DoLs (Deprivation of Liberty) authorisation required?

Please give the date of any existing DoLs in place

Give brief detail of any existing DoLs in place

Is this person consenting to be assessed for Residential care?

Is a Best Interest Decision Meeting required prior to admission?

Function details

Section 9

Do they have aids, spectacles or hearing aids?

Please state which ones here

Any issues with the following?

Way of Communicating e.g. Speech – first language / dysphasia. Hearing. Sight – diseases / degeneration. Please add details below.

Breathing…

e.g. Respiratory problems. Special requirements: O2 / nebulisers.

Eating/Drinking/Nutrition

e.g. Oral health / frequency of dental visits. Appetite / Fluid intake. Sense of smell ? Dietary preferences / requirements. Nutritional needs / Support. Adapted utensils? Allergies? Swallowing issues? SALT assessment. Weight loss issues?

Do they have dentures?

If yes, please specify upper or lower

Height if known (in cm)

Last recorded weight (in kg)

Date of last recorded weight

MUST Score if known

Elimination (please add details below)

e.g. Continence needs & products. Pain. Night routine for elimination. History – UTI / Constipation. Equipment, skin condition, medication, catheters, access to WC and frequency.

Personal Hygiene

Please state e.g. Preference: Female / male carer. Bath / Shower / Washing. Hair – wash / cut / set. Dressing. Foot Care / finger nails. Oral Hygiene. (? word)Assistance / Supervision. Aids / Prosthesis.

Mobilising

Please add details. e.g. Past injuries, contractures / deformities. Falls history. Standing - aids. Transferring - aids. Walking aids. Wheelchair - routine. Steps / stairs. Balance / footwear. Seating / behaviour.

Maintaining a safe environment

Please add details. e.g. Controlling body temperature. History of falls. Wandering / Absconding. Personal safety and risks. Equipment / aids / adaptations.

Skin integrity

Please add details. e.g. Condition of skin: Intact / Broken areas? Dry / paper thin / diseased / tears. Rashes / Blisters. Pressure Injuries / Care(Category / Dressings). Bruises / Swellings. TVN involved ? Nursing requirements: specialist beds or turning?

Waterlow Score if known

Working/Leisure

Please give details. e.g. Social Care. Social/introvert. Past and present employment. Community involvement. Day centres. Hobbies. Family. Spiritual needs. Religious beliefs. Cultural needs. Religious and /or spiritual needs. Preferences. Family involvement in the person's care.

Sleeping

e.g. Position change. Night time routine Medication. Preferences. Nocturnal rising. Equipment / adaptations.

Night time routine

eg, How well do they go to bed? Do they sleep through the night? If not, how many times do they wake and what level of assistance is needed?

Footcare

Are there any highlighted problems with feet? e.g. Diabetic. Peripheral circulation.

Chiropodist?

Frequency of visits

Vaccination status

Section 9

Covid-19 Vaccination - last vaccination date

Flu Vaccination - last vaccination date

Are they able to communicate verbally?

South Devon Care Services Pre-Assessment Form

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