Form 3091 "Comprehensive Nursing Assessment" - Texas

What Is Form 3091?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 3091 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form 3091 "Comprehensive Nursing Assessment" - Texas

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Form 3091
September 2020-E
Home and Community Based Services Adult Mental Health (HCBS-AMH)
Comprehensive Nursing Assessment
To be performed by a Registered Nurse
Name of Individual
Date of Birth (MM/DD/YYYY)
Today's Date (MM/DD/YYYY)
Address
Gender
Race
Married Status
Education
Language
Single
Married
Separated
Divorced
Widowed
I. Review
Review of Health Care Team
Date
Health Care Practitioners
Last Seen
Comments
Primary Care
Psychiatrist
Neurologist
Dentist
Optometrist
Natural Supports
Relationship
Telephone No.
Legally Authorized Representative (LAR), if applicable
Chief Complaint, Presenting Problem, Psychiatric and Medical Diagnosis, Medical History
Chief Complaint (Subjective):
Presenting Problem (Objective):
Psychiatric Diagnoses (including substance use):
Medical Diagnoses:
Major Medical/Surgical History (refer to Form 3090, Nursing Health Screening Within 72 Hours of Community Placement):
RN:
Form 3091
September 2020-E
Home and Community Based Services Adult Mental Health (HCBS-AMH)
Comprehensive Nursing Assessment
To be performed by a Registered Nurse
Name of Individual
Date of Birth (MM/DD/YYYY)
Today's Date (MM/DD/YYYY)
Address
Gender
Race
Married Status
Education
Language
Single
Married
Separated
Divorced
Widowed
I. Review
Review of Health Care Team
Date
Health Care Practitioners
Last Seen
Comments
Primary Care
Psychiatrist
Neurologist
Dentist
Optometrist
Natural Supports
Relationship
Telephone No.
Legally Authorized Representative (LAR), if applicable
Chief Complaint, Presenting Problem, Psychiatric and Medical Diagnosis, Medical History
Chief Complaint (Subjective):
Presenting Problem (Objective):
Psychiatric Diagnoses (including substance use):
Medical Diagnoses:
Major Medical/Surgical History (refer to Form 3090, Nursing Health Screening Within 72 Hours of Community Placement):
RN:
Form 3091
Individual:
Date:
Page 2 / 09-2020-E
Review of Current Medications
Include OTCs, vitamins and herbs
Allergies:
Medication
Dose
Freq.
Route
Purpose/Rationale
Side Effects/Labs
RN:
Form 3091
Individual:
Date:
Page 3 / 09-2020-E
II. Current Status
Current medical and psychiatric status
Briefly describe recent changes in health or behavioral status, recent hospitalizations, falls, seizure activity, restraints, etc., within the past year.
What is of primary concern/greatest expressed needs of the individual or LAR from their own perspective?
Vital Signs
Blood Pressure
Pulse
Respirations
Rate
Rhythm
Rate
Rhythm
Temperature
Pain level
Blood Sugar
Weight
Height
BMI
Comments
Labs
Briefly review ordered labs, dates and abnormal values within the past year.
RN:
Form 3091
Individual:
Date:
Page 4 / 09-2020-E
Fall Risk Assessment
Comments
Has a fall risk assessment been completed?
No
Yes (attached). Fall risk due to:
Neurological
Musculoskeletal
Unknown/Other
III. Review of Systems
Neurological
Abnormal Involuntary Movement Scale (AIMS) Assessment:
Attached
Deferred
Y
N
Y
N
Y
N
Pupils equal and reactive to
Headaches ........................
Heat/cold reflex ..........................
light and accommodation
Dizziness...........................
Tremors ...........................
Extrapyramidal symptoms ..........
Impaired balance/
Numbness/tingling/
coordination .......................
Paresthesia .......................
Medication side effects .........
Paralysis ...........................
Y
N
Y
N
Y
N
Seizures ............................
Petit Mal ...........................
Clonic (repetitive jerking) ...........
Frequency
Absence............................
Tonic (muscle rigidity) ................
Myoclonic
Duration
Atonic (loss of muscle tone) .......
(sporadic Jerking) ...............
Comments
Eye, Ear, Nose and Throat
Eye/Vision
Clear
Red
Right impaired
Left impaired
Adaptive aid
Ears/Hearing
Normal
Ringing
Right impaired
Left impaired
Adaptive aid
Nose/Smell
Within normal limits
intact
not intact
Nose bleed
Frequent sinus congestion
Smell:
Frequent sinus infection
RN:
Form 3091
Individual:
Date:
Page 5 / 09-2020-E
Oral
Within normal limits
Difficulty chewing
Mouth pain
Halitosis
Dentures
Edentulous
Involuntary tongue movement
Dry mouth from medications
Throat
Within normal limits
Sore throats
Difficulty speaking
Difficulty swallowing
Tonsil enlargement
Thyroid enlargement
History of choking
Date:
Swallow Study:
Yes
No
Results:
Comments
Cardiovascular
Y
N
Y
N
Y
N
Capillary refill less than or equal
Chest pain .........................
Cool/Numb extremities ...........
to two seconds ...................
Activities of daily living (ADL)
Edema ..............................
Compression stockings ........
limitations ............................
High/Low blood pressure ......
Normal range:
Comments
Respiratory
Breathing:
Slow
Normal
Rapid
Shallow
Painful
Y
N
Y
N
Y
N
Short of breath....................
Feeding tube............................
Tracheostomy....................
Continuous positive airway
Wheezing ..........................
Positioning orders .....................
pressure (CPAP) ................
Cough...............................
Aspiration history .......................
Inhalation agent .................
Productive .........................
Pneumonia history .....................
Pulse Oxygen @
Comments
RN:
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