"Long Term Care and Community Support Program Adult Needs Reassessment" - Newfoundland and Labrador, Canada

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Long Term Care and Community Support Program
Adult Needs Reassessment
This form is completed annually and only when there is minimal or no change in a client’s condition and
services are still required.
Record appropriate changes in function since last assessment and effects of these changes on level of
independence.
Name:
RHA File #:
Address:
CRMS File #:
MCP #:
Postal Code:
Date Reassessment completed:
Telephone #:
EMERGENCY CONTACT
FAMILY CONTACT
(
(
Record only if contact information has changed)
Record only if contact information has changed)
Name:
Name:
Address:
Address:
Postal Code:
Postal Code:
Telephone #: Residence:
Telephone #: Residence:
Business:
Business:
Relationship:
Relationship:
What recent event(s) precipitated this Reassessment?
Assessor’s Signature:
Profession:
Telephone Number:
Date:
Long Term Care and Community Support Program
Adult Needs Reassessment
This form is completed annually and only when there is minimal or no change in a client’s condition and
services are still required.
Record appropriate changes in function since last assessment and effects of these changes on level of
independence.
Name:
RHA File #:
Address:
CRMS File #:
MCP #:
Postal Code:
Date Reassessment completed:
Telephone #:
EMERGENCY CONTACT
FAMILY CONTACT
(
(
Record only if contact information has changed)
Record only if contact information has changed)
Name:
Name:
Address:
Address:
Postal Code:
Postal Code:
Telephone #: Residence:
Telephone #: Residence:
Business:
Business:
Relationship:
Relationship:
What recent event(s) precipitated this Reassessment?
Assessor’s Signature:
Profession:
Telephone Number:
Date:
File #:
PHYSICAL ACTIVITIES OF DAILY LIVING
Physical Activities of Daily Living
Ind
Min
Mod
Dep
TD
N/A
COMMENTS (Refer to specific ADL when commenting, ie. ambulation)
Grooming (ie., facial wash, mouth care, combing
hair, etc.)
Shaving
Hair Care (Shampoo, style, etc.)
Skin Care
Hand Care
Wash Hands
Trim Nails
Foot Care
Care for Feet
Trim Nails
Bathing
Tub/Shower
Sponge
Bed
Dressing
Upper Extremities
Lower Extremities
Eating
Toileting
Ambulation
Transfer
Turning/Positioning
(Ind)
Independent
needs no assistance, may use special devices
(Min)
Minimal Assistance/Cueing
needs reminding or occasional supervision/assistance
(Mod) Moderate Assistance/Supervision
needs intermittent supervision or assistance to complete some tasks, may use special devices
(Dep)
Dependent/Constant Supervision
needs constant critical watching to give direction or complete task or someone else to perform function
(TD)
Technology Dependent
needs a medical device to compensate for loss of a vital body function and ongoing professional care, e.g. ventilator,
etc.
(N/A)
Not Applicable
does not apply
Assessor:
Profession:
Telephone #:
Date:
2
File #:
INSTRUMENTAL ACTIVITIES OF DAILY LIVING
COMMENTS (Refer to specific IADL when commenting, ie. shopping)
Instrumental Activities of Daily Living
Ind
Min
Mod
Dep
N/A
Meal Preparation
Laundry
Bathroom/Kitchen
Home Management
Bedmaking/Dusting
Light Vacuuming
Other
Ability to use Telephone
Personal Financial Affairs
Medication
Transportation
Shopping
Yard Work
Snow Removal
(Ind)
Independent
needs no assistance, may use special devices
(Min)
Minimal Assistance/Cueing
needs reminding or occasional supervision/assistance
(Mod) Moderate Assistance/Supervision
needs intermittent supervision or assistance to complete some tasks, may use special devices
(Dep)
Dependent/Constant Supervision
needs constant critical watching to give direction or complete task or someone else to perform function
(N/A)
Not Applicable
does not apply
Assessor:
Profession:
Telephone #:
Date:
3
File #:
SUMMARY AND RECOMMENDATIONS
SUMMARY
Descriptors to Consider
orientation/cognition
physical assessment
physical activities of daily living
instrumental activities of daily living
behavioral assessment
mental health assessment
social assessment
environmental assessment
personal hobbies/interests
equipment (to accompany, or
required)
changes in life circumstances
CURRENT SERVICES
perception of needs
client’s strengths
client’s limitations
current conflict/stress
other family/caregiver dynamics
RECOMMENDATIONS
Assessor’s Signature:
Profession:
Telephone Number:
Date:
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