LOWELL GENERAL HOSPITAL

ADULT OUTPATIENT INITIAL ASSESSMENT

(ACU,PRESCREENING)
Date

Time

Name/Label

Family Spokesperson/Relationship and

phone#:___________________________________________________________________

ID Band in Place

Preferred Language: English Other________________________ Interpreter Offered: Name ____________________________ Declined Interpreter Services
Information Obtained: Patient

Significant Other

Family Extended Care Facility

Advanced Directive Health Care Proxy: On File Information Given Name of proxy ______________________________________________ PCP_________________________
CHIEF COMPLAINT / REASON FOR ADMISSION / PLANNED PROCEDURE:

VITAL SIGNS

RR

PAIN LEVEL

Current: _____ / 10

Max _____ / 10

Pain related to chief complaint? Yes / No; Acute / Chronic

BP

Patients Pain Goal ___________

Unconscious Patient Assess & document behaviors & physiologic changes consistent with pain.

02SAT

Weight (kg)

Height

Onset ________________________________________________________________
Location______________________________________________________________
Duration______________________________________________________________
Characteristics_________________________________________________________
Aggravating___________________________________________________________
Relieved______________________________________________________________
Treatment_____________________________________________________________
PROBLEMS: YES NO

ALLERGIES

ALLERGIES / INTOLERANCES (Include medication, food, environment, latex, contrast media)

No Known Allergies

Reaction Codes: (1) Anaphylactic reactions (2) Breathing problems (3) ENT swelling (4) Mental changes (5) GI disturbances (6) Skin reactions
Severity Codes: (M) Mild (MO) Moderate (S) Severe
Allergy/Intolerance
Reaction & Severity Codes
Allergy/Intolerance
Reaction & Severity Codes

Shellfish

Iodine

IV Contrast

Latex

No Known Allergies

PAST MEDICAL HISTORY

Cardiac / Vascular

No history

Hypertension

MI/Angina

Metabolic/Endocrine

No history

Diabetes

Cardiac disease

Heart Failure

Pacemaker

Defibrillator

Psychiatric Illness

No history

Depression Anxiety

Cardiac surgery

Valve replacement

VAD

Other

Musculoskeletal

No history

Joint replacement

Arthritis

Other

Respiratory

No history

COPD

Tuberculosis

Pneumonia

Asthma

Sleep apnea

Other

Cancer

No history

Yes If yes, describe:

No history

Yes If yes, describe:

PVD

GI/GU/GYN

No history

Hepatitis

GYN problems

Kidney Stones

GI Bleed

Pancreatitis

GU problems

Surgery

Kidney Disease

GERD

Other

Prostate

Anesthesia Problems

Neurologic

No history

Dementia

Migraines

Comments:

Seizures

Other

Vision/Hearing Problems
EENT

CVA

Cataracts

Other
Other

History of falls

LMP_______________

Alcohol Intake __________________ Substance Abuse __________________________________________

Would you want to speak with someone about this? Yes No
CURRENT MEDICATIONS / HERBS / VITAMINS
Medication

Thyroid disease

Dose

Smoking PPD ______

( List Prescription, Over-the-counter Drugs, Vitamin/Mineral Supplements, Herbs, Home Remedies)

Frequency

Time of last dose

Medication

Dose

Taking no medications
Frequency

Time of last dose

Comments & focused physical assessment: __________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________

Signature:
Z:nadmin/Assessment Forms/Adult Assessment Outpatient ACU Prescreening 04/16/04 , 06/28/04, 101904 ; 10/11/05 MR# 2002-015

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NAME:

MEDICAL RECORD #:

PROBLEMS: YES NO

FUNCTIONAL SCREEN

PT Orthopedic Surgery

OT ________________________________________________

PT Crutches/Walker

Speech ____________________________________________

PHYSICAL THERAPY REFERRAL

Date / Time Notified ___________
OT / PT / SPEECH THERAPY REFERRAL
Date / Time Notified ___________

PT Other
NUTRITIONAL ASSESSMENT
NPO Since _______________________

PROBLEMS: YES NO
NUTRITION REFERRAL
Date / Time Notified: _________

N Initial enteral feeding placement

MENTAL STATUS
Alert
Disoriented
Unconscious
Developmentally Delayed
Oriented
Confused
Combative
Other
Does the patient demonstrate present behaviors and or have a past medical history that puts him/her at risk for
Harming self and/or others? Yes No If yes, ask the patient to describe techniques, methods and/or tools that
have helped to de-escalate behaviors. __________________________________________________________________

PROBLEMS: YES NO

LEARNING ASSESSMENT
1. Readiness to Learn

2. How Do You Learn

3. Barriers to Learning

(explain all checked)

4. Learning Needs

PROBLEMS: YES NO

High
Reading
Communication Deficit
Language
Memory deficit
Patient

Disease

Medications

Diet

Other

Check in
function

Medium
Listening
Literacy
Hearing/Visual

Family

Poor
Demonstration
Psychosocial/Anxiety
Other None
Patient

Treatment
Pain Management
Equipment
Surgery

Family

ABUSE ASSESSMENT

PROBLEMS: YES NO
S
OCIAL
WORKER REFERRAL
1. Do you feel safe at home? Yes SW No
If No, Why Not? ___________________________
2. Have you been hurt physically, verbally, emotionally, sexually, or financially exploited by someone within the past year? Date / Time Notified:_____________
SW Yes No Please explain. _____________________________________
3. Would you like to discuss this with a member of our staff? SW Yes No
Domestic Violence Notice Given Yes
VALUE ASSESSMENT
Is there any conflict between your religious/cultural beliefs that are in conflict with your medical treatment? Yes No
Religion:

PROBLEMS: YES NO

PRELIMINARY DISCHARGE PLANNING

Return home with responsible adult
Name: ______________________________________
CM Home services anticipated

PROBLEMS: YES NO

LIVING
SITUATION
SUPPORT
SYSTEMS

CM Transportation arrangements for discharge

CM Return to previous facility

Alone

CM

Assisted Living

CM

Elder Services/VNA

SW

Homeless

CASE MANAGEMENT REFERRAL

With Family/Friends

CM

Nursing Home

CM

Group home

CM

History of falls

Date Time Notified:______________

DeferredPatient Condition
Completed:
Date / Time / Initial:______________
PROBLEMS: YES NO

CM > 80Yrs living alone

Spouse/Significant Other

Other

Escort Home:

Friends

Involved family

Uninvolved family

SW None
Other
ADDITIONAL NOTES: __________________________________________________________________________________________________________________
Neighbors

____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
_____________________________________________________________________________________________PreScreen
Date:
Time:
ing RN:
Z: nadmin/Assessment Forms/Adult Assessment Outpatient ACU,Prescreening 04/16/04 , 06/28/04, 101904

MR# 2002-015

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