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Form from HIS OpenVista

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  1. 3/9/12
  2. 6/8/17
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June 8, 2017

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Creative Commons BY-NC 3.0
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SOCIAL SERVICES PSYCHOSOCIAL ASSESSMENT NOTE

HIS

  1. StudyEvent: HIS
    1. HIS
Psychosocial Assessment
INFORMANT
LANGUAGE/COMMUNICATION BARRIER
DISCUSSED ADVANCE DIRECTIVE WITH PATIENT
PATIENT HAS EXECUTED AN ADVANCE DIRECTIVE
IS ADVANCE DIRECTIVE FORM IN THE ELECTRONIC RECORD?
Therapien
HBO
Occupational Therapy
Physical Therapy
Phototherapy
Radiation / Chemotherapy
Atemtherapie
Speech Therapy
Wound Care
None
Time of Patient's condition
THE FOLLOWING ASSESSMENT REFLECTS THE PATIENTS' CONDITION
Patient Status
Alert
Disoriented
Comatose
Speech impairment
Vision impairment
Hearing impairment
Living Situation
Lives with family
Lives with spouse
Pflegeheim
Foster home
Home alone
FINANCIAL INFORMATION
employed
unemployed
commercial insurance
MEDICAID
MEDICARE
SS
SSD
SSI
AFDC
CSHCN
CHIP
MCHD
VA
No Income
SUPPORT SYSTEM
Spouse/Family
Church
Agency
None
CAREGIVER
Self
Spouse/Family
Friend
Agency personnel
Community Clinic
SKILLED NEEDS
intravenöse Therapie
Foley Catheter Care
Ostomy Care
Wound Care
Feeding Tube Care
Dialysis
Drain Care
Ventilator
None
CURRENT ASSISTIVE DEVICES EQUIPMENT NEEDS
Wheelchair
Crutches
Walker
Cane
Hospital Bed/Rails
Hoyer lift/Trapeze
Oxygen
Apnea Monitor
Carseat
Crib
None
DAILY LIVING ACTIVITY
Wheelchair
Bedbound
Inkontinenz
Hygiene preparation
Meal preparation
Ernährung über Sonde
Grooming / Dressing
Shopping
Laundry
Cleaning
Total independence
Mobility impaired
No assistance required
PSYCHOSOCIAL ASSESSMENT
RELIGIOUS/CULTURAL PREFERENCE
POSSIBLE NEEDS
No Needs evident
Adoption
Adult protective Services
Assistance ADL's
Child protective Services
Counseling / Therapy
Ausbildung
Equipment
Financial Resources
Food / Clothing
Home health
Hospice
Housing
Lifeline / ERS
LTAC
Medication / Supplies
PBCCMHMR
Meals on Wheels
Nursing facility placement
Other hospital
Rehabilitation
Safe Place
Skilled Nursing Facility
Substance abuse treatment
Support Group
Transportation
WIC
Other
AT THIS TIME CONTINUED INTERVENTION IS