Care Assessment

2.[ResProf]_Care_Assessment

This form needs to be completed by Registered Nurse/Enrolled Nurse.
(With reference to Western Cape Social Development, aged/DQ98/wicht scale)

Name

Date of birth

Age

Date

Gender

Name of Elder Community

Unit/Home

Department

Moved In

Medical Diagnosis

MOBILITY

Mobility

PERSONAL HYGIENE

Washing of hands, feet and face

Mouth Care

Bathing

Shaving and Hair care

NUTRITION

Nutrition

DRESSING

Dressing

SIGHT

Sight

HEARING

Hearing

TREATMENT

Medication

Care of Presssure Areas

CONTINENCE

Continence

THERAPEUTIC ACTIVITIES, HANDCRAFTS, EXERCISES AND INFO

Therapeutic activities, handcrafts, exercises and info

MEMORY STATUS

Memory

Emotional Support

Comprehension and Communication ability

Orientation re: time, place and person

KEYS TO SCORE ALLOCATION

Results

Group 1: Selfcare 0 – 11

Group 2: Medium Care 12 – 25

Group 3: Maximum Care 26+

Total

Group 1: Selfcare 0 – 11

Group 2: Medium Care 12 – 25

Group 3: Maximum Care 26+

CARE DIAGNOSIS

Assessed by

Date completed

Sign of details

No Yes

Signature

Clear

Signed off by HCM/RN:

Clear

Date completed

If you are human, leave this field blank.