Aaitivily Independent | _ Needs assissiance Dependent in PT Reteral mand needed it Eating eat ‘uneti "Dependent Functional Teething 122 "Needs Assis- Dressing hae Tolet needs itera i= a 7 z 3 Hiss ead lake dosed verte pat 3 mee due ove ot appt, dgesiv robin, ching ot swalonig caen? | Severe Moderate No Unhealthy Weigt oss in last 3 months 73K Dont know | 3K | Noloss Mini [_Mobity Bed/chairbound | Able 9 but Faby | Autttional | Route disease nest S months Yes No me = ‘Neutopsycholagical problem Severe dementia [MITT None | Body habitus Cachectic/ Morbid | Obese | Thin _| Average TOTAL SCORE Screoning Score = (Sub Total Max.14) Ti hone kanoaiomne santana —_ | Fall Score Fall Risk Risk ‘Score TTick the appropriate one Assessment | [High Risk | 45 & Higher Sane Moderate Risk | 35-44 les Low Risk 0-34 Seas Sates ass al ean eae Assessment iz Nursing Care Plan Problems ‘Assessments Plans | Functional Dependent Assisstance Independent PT referral: Yes No Meal Type: Nutritional : MNA Score Dietary referral: Yes No. informed o Dietician Yes No Patient Safely Patient education & Language: “Spoken Reading communication Needs: Personal hygiene Monitoring / Equipment Mosication Investigations Away Elimination Activity Skin Care = Wound W ‘Nurse's Sign / Name / Date / Time: