2/1/14

Discharge Plan Considerations

Projected length of stay (hours/days):________________________ 
Anticipated date of discharge:_______________________________
Date information obtained:________________________________ Source:________________________________________
Resources available: Persons:________ Financial:________ Community supports:________ Groups:________
Areas that may require alteration/assistance: Food preparation:_____ Shopping:_____ Transportation:_____ Ambulation:_____
Self-care (specify):________________________________ Socialization:________________________________
Medication/IV therapy:________________ Treatments:________________ Wound care:________________ Supplies:________________
Homemaker/maintenance(specify):________________________ 
Physical layout of home (specify):________________________
Anticipated changes in living situation after discharge:________________ 
Living facility other than home (specify):________________
Referrals (date/source/services): Social services:________________________ Rehabilitation:________________________
Dietary:________ Home care:________ Resp/O2:________ Equipment:________ Supplies:________ Other:________
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Teaching/Learning Assessment Tool

Subjective (Reports)
Communication: Dominant language (specify):____________________________ 
Second language:____________________________
Literate (reading/writing):_________________________________________________________________________
Education level:______________ Learning disabilities (specify):______________ 
Cognitive limitations:________________
Culture/ethnicity:______________ Where born:______________ 
If immigrant, how long in this country:__________________
Health and illness beliefs/practices/customs:________________________________________________________
Which family member makes healthcare decisions/is spokesperson for client:_____________________________
_____________________________________________________________________________________________
Presence of Advance Directives:_______ Code status:_______ Durable Medical Power of Attorney:_______ Designee:______
Health goals:__________________________________________________________________________________
Current health problem:____________________________ 
Client understanding of problem:________________________________
Special healthcare concerns (e.g., impact of religious/cultural practices, healthcare decisions, family involvement):_______
Familial risk factors (indicate relationship):_______ Diabetes:_______ Thyroid (specify):_______ Tuberculosis:_______ Heart disease:_______
Stroke:___________________________________ High BP:___________________________________
Epilepsy/seizures:_______ Kidney disease:_______ Cancer:_______ Mental illness/depression:_______ Other:_______

 Prescribed medications (list each separately):
Drug:_____________________ Dose:_____________________ Times (circle last dose):_____________________
Take regularly:_____________________ Purpose:_____________________ Side effects/problems:_____________________

 Nonprescription drugs/frequency:
OTC drugs:______________ Vitamins:______________ Herbals:______________ Street drugs:______________
Alcohol (amount/frequency):______________ Tobacco:______________ Smokeless tobacco:______________
Admitting diagnosis per provider:____________________________________________________________________________________
Reason for hospitalization/visit per client:___________________________________________________________
History of current problem/concern:________________________________________________________________
Client expectations of this hospitalization/visit:_______________________________________________________
Will admission cause any lifestyle changes (describe):________________________________________________
Previous illnesses and/or hospitalizations/surgeries:__________________________________________________
Evidence of failure to improve:____________________________________________________________________

Last complete physical examination:______________________________________________________________
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Sexuality (Component of Social Interaction) Assessment Tool

Subjective (Reports)

 Sexually active:______________ Monogamous/committed relationship:______________ 
Use of condoms:______________
Birth control method:
_________________________________________________________________________________
Sexual concerns/difficulties: Recent change in frequency/interest: Pain/discomfort:__________________________

Objective: (Exhibits)
Comfort level with subject matter:___________________________________________________________________________

Female: Subjective (Reports)
Menstruation: Age at menarche:_______ Length of cycle:_______ Duration:_______ Number of pads/tampons used/day:_______ Last menstrual
period:_______ Bleeding between periods:_______ Menopausal:_______ Last period:_______ Hysterectomy (type/date):_______ Problems
with: Hot flashes:_______ Night sweats:_______ Vaginal lubrication:_______ Vaginal discharge:_______
Gynecological/breast surgery (type and date):____________________________________________________
______________________________________
Infertility concerns:___________________________________ Type of therapy:_________________________
Pregnant now:__________________ Para:__________________ Gravida:__________________ 
Due date:__________________
Practices breast self-examination:______________ Last mammogram:______________ 
Last Pap smear/results:______________
Hormonal therapy:______________ Supplemental calcium:______________ 
Other medications/herbals:______________

Objective (Exhibits)
Breast examination:__________________________________________________________________________________
Genitalia:__________________ Warts/lesions:__________________ 
Vaginal bleeding/discharge:__________________
Test results: __________________Pap:__________________ Mammogram: STD:__________________

Male: Subjective (Reports)
Penis: Circumcised:____________________ Lesions/discharge:____________________ Vasectomy:_____________________
Prostate disorder/voiding difficulties:_______________________________________________________________________
Practice self-examination: Breast:____________________________ Testicles:____________________________
Last proctoscopic/prostate examination:____________________________ 
Last PSA:____________________________
Medications/herbals:_________________________________________________________________________________________________________________________________________________________________________

Objective (Exhibits)
Genitalia: Penis:_______ Warts/lesions:_______ Bleeding/discharge:_______ Testicles (e.g., descended, lumps):_______
Prostate:_____________________________________________________________________________________________________
Breast examination:____________________________________________________________________________
_________________________________________
Test results:_______________________________ STD:_______________________________ PSA:_______________________________
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Safety Assessment Tool

Subjective (Reports)
Allergies/sensitivity (medications, foods, environment, latex):___________________________________________
__________________________________________________
Type of reaction:_______________________________________________________________________________
Blood transfusion/number:______________ Date:______________ Reaction (describe):______________

 Exposure to infectious diseases (e.g., measles, influenza, pink eye):
_____________________________________________________________________________________________
Exposure to pollution, toxins, poisons/pesticides, radiation (describe reactions):
_____________________________________________________________________________________________
Geographic areas lived in/recent travel:
_____________________________________________________________________________________________
Immunization history/date: Tetanus:_______ MMR:_______ Polio:_______ Hepatitis:_______ Pneumonia:_______ Influenza:_______ HPV:_______
Altered/suppressed immune system (list cause):
_____________________________________________________________________________________________
History of sexually transmitted disease (date/type):________________________________ Testing:_________________________________
High-risk behaviors (specify):
_____________________________________________________________________________________________
Uses seat belt regularly:______________ Uses bike helmet:______________ Other safety devices:______________
Work place safety/health issues (describe):_______ Occupation:_______ Currently working:_______ 
Rate working conditions (e.g.,safety, noise, heating, water, ventilation):
_____________________________________________________________________________________________
History of accidental injuries:____________________________ Fractures/dislocations:____________________________
Arthritis/unstable joints:__________________________________________ 
Back problems:__________________________________________
Skin problems (e.g., rashes, lesions, moles, breast lumps, enlarged nodes)/describe:_______________________
_________________________________________
Delayed healing (describe):______________________________________________________________________
_________________________________________
Cognitive limitations (e.g., disorientation, confusion):__________________________________________________
___________________________________________
Sensory limitations (e.g., impaired vision/hearing, detecting heat/cold, taste, smell, touch):__________________
___________________________________________
Prosthesis:____________________________ Ambulatory devices:____________________________
Violence (episodes or tendencies):________________________________________________________________
____________________________

Objective (Exhibits)
Body temperature/method (e.g., oral, rectal, tympanic):_______________________________________________
Skin integrity (mark location on diagram):_______ Scars:_______ Rashes:_______ Lacerations:_______ Ulcerations:_______ Bruises:_______
Blisters:______________ Drainage:______________ Burns (degree/% of body surface):______________
Safety Assessment Tool 
Musculoskeletal: General strength:________ Muscle tone:_________ Gait:________ 
ROM:______ Paresthesia/paralysis:_____
Results of testing (e.g., cultures, immune function, TB, hepatitis):___________________________
_________________________________________________________________________________
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Respiration Assessment Tool

Subjective (Reports)
Dyspnea/related to: _______________ Precipitating factors:_______________ 
Relieving factors:_______________
Airway clearance (e.g., spontaneous/device):________________________________________________________
Cough (e.g., hard, persistent, croupy):_______________ Sputum color/character:_______________ Requires suctioning:_______________
History of/date: Bronchitis:_____ Emphysema:_____ Tuberculosis:_____ Recurrent pneumonia:_____ 
Exposure to noxious fumes/allergens, infectious agents/diseases, poisons:
_____________________________________________________________________________________________
Smoker:__________ packs/day:__________ # of pack years:__________ Cigar use:__________ Smokeless:__________
Use of respiratory aids:_________________________ Oxygen (type & frequency):_________________________
Medications/herbals:______________________________________________________________________________________________________________

 Objective (Exhibits)
Respirations (spontaneous/assisted):_____ Rate:_____ Depth:_____ Chest excursion (e.g., equal/symmetrical):_____ 
Use of accessory muscles:_______________ Nasal flaring:_______________ Fremitus:_______________
Breath sounds (describe):_________________________ Egophony:_________________________
Skin/mucous membrane color (e.g., pale, cyanotic):____________________ 
Clubbing of fingers:______________________
Sputum characteristics:_________________________________________________________________________
Mentation (e.g., calm, anxious, restless):_______________________________________________________________________
Pulse oximetry:_____________________________________________________________________________________
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Pain/Discomfort Assessment Tool

Subjective (Reports)

 Primary focus:Location:______________________ Intensity (use pain scale/pictures):______________________
Quality (e.g., stabbing, aching, burning):____________________________ Radiation:____________________________
Frequency:_______________________________________________ Duration:_________________________________________________
Precipitating/aggravating factors:__________________________________________________________________
How relieved: OTC/prescription:____________________________ Nonpharmaceuticals/therapies:___________________________
Associated symptoms (e.g., nausea, sleep problems, photosensitivity):__________________________________
Effect on daily activities:______________ Relationships:____________ Job:____________ 
Enjoyment of life:____________
Additional pain focus/describe:________________________________________________________________________________
Cultural expectations regarding pain perception and expression:
_____________________________________________________________________________________________

 Objective (Exhibits)
Facial grimacing:_________ Guarding affected area:_________  Posturing:_________  Behaviors:_________  Narrowed focus:_________ 
Emotional response (e.g., crying, withdrawal, anger):
_________________________________________________________________________________________
Vital sign changes (acute pain): BP:__________________ 
Pulse:__________________ 
Respirations:__________________
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1/31/14

Neurosensory Assessment Tool

Subjective (Reports)

 History of brain injury, trauma, stroke (residual effects):______________________________________________
Fainting spells/dizziness:_____________________ Headaches (location/type/frequency):__________________
Tingling/numbness/weakness (location):__________________________________________________________
Seizures:______ History/onset:______ Type (e.g., generalized, partial):______ Frequency:______ 
Aura (describe):______
Postictal state:__________________________________How controlled:________________________________
Vision loss/changes:____ Glasses/contacts:____ Last exam:____ Glaucoma:____ Cataract:____ Eye surgery (type/date):____
Hearing loss:__________________ Sudden/gradual:__________________ Hearing aids:__________________ Last exam:__________________
Sense of smell (changes):____________________________________ Epistaxis:____________________________________
Sense of taste (changes):_______________________________________________________________________
Other:_______________________________________________________________________________________

Objective (Exhibits)

 Mental status (note duration of change):
Oriented: Time:__________________ Place:__________________ Person:__________________ Situation:__________________
Check all that apply:_________ Alert:_________ Drowsy:_________ Lethargic:_________ Stuporous:_________ Comatose:_________
Cooperative:____________ Follows commands:____________ Agitated/restless:____________ Combative:____________
Delusions (describe):____________________________ Hallucinations (describe):_________________________
Affect (describe):____________________________________ Speech:______________________________________________
Memory:Recent:_________________________________ Remote:_________________________________
Pupil shape:_______________________ Size/reaction: R/L:_______________________ Accommodation:_______________________
Facial droop:______________________________________________ Swallowing:_____________________________________________
Handgrasp/release, R:______________________________________ L:______________________________________________________
Coordination:_______________________ Balance:_______________________ Walking:_______________________
Deep tendon reflexes (present/absent/location):_________ Tremors:________ Posturing:________ Paralysis (L/R):_______
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Hygiene Assessment Tool

Subjective (Reports)

 Ability to carry out activities of daily living: Independent/dependent (level 1, no assistance needed, to level 4, completely dependent):

Mobility:_______________ Needs assistance (describe):_______________ 
Assistance provided by:_______________
Equipment/prosthetic devices required:_____________________________________________________________
Feeding:_______________ Needs assistance preparing/eating (describe):_______________ 
Assistive devices:_______________
Bathing:_______________________ 
Needs assistance setup/regulating water temp/washing body parts (describe):_______ 
Preferred time of personal care/bath:_______________________________________________________________
Dressing:_______________ Needs assistance selecting clothing/dressing self (describe):___________________
Toileting:_______________ Needs assistance transferring/cleaning self (describe):_________________________

 Objective (Exhibits)
General appearance:_____________ Manner of dress:_____________ Grooming/personal habits:_____________
Condition of hair/scalp:__________________________________________________________________________
Body odor:_________________________ Presence of vermin (e.g., lice, scabies):__________________________
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Food/Fluid Assessment Tool

Subjective (Reports)

 Usual diet (type):_______ Calorie/carbohydrate/protein/fat (g/day):_______ # of meals daily:_______ 
Snacks (# daily, time consumed, type):____________________________________________________________
Last meal consumed/content:____________________________________________________________________
Food preferences:_________________________________ 
Food allergies/intolerances:_________________________________
Cultural or religious food preparation concerns/prohibitions:___________________________________________________________________________
Usual appetite:_________________________________ Change in appetite:_______________________________
Usual weight:_________________________________ 
Unexpected/undesired weight loss or gain:_________________________________
Nausea/vomiting:_______ related to?_______ Heartburn/indigestion:_______ related to?_______ 
relieved by?_______
Chewing/swallowing problems:_________________________________ Gag/swallow reflex (present):_________________________________
Facial injury/surgery:_________________________________ Stroke/other neurologic deficit:____________________________________
Teeth: Normal:____________ Dentures (full/partial):____________ Loose/absent teeth:____________ 
Sore mouth/gums:____________
Dental hygiene practices:_________________________________ 
Professional dental care/frequency:______________________________
Diabetes/type:_________________________________ 
Controlled with diet/pills/insulin:_________________________________
Vitamin/food supplement use:_________________________________ Medications/herbals:__________________________________

 Objective (Exhibits)
Current weight:_________________ Height:_________________ Body build:_________________ 
Body fat %:________________
Skin turgor (e.g., firm, supple, dehydrated):_________________ 
Mucous membranes (moist/dry):_________________
Edema (describe):_______ Generalized:_______ Dependent:_______ Feet/ankles:_______ Periorbital:_______ Abdominal/ascites:_______
Jugular vein distention:___________________________________________________________________________________
Breath sounds (auscultation)/location:_______ Normal:_______ Diminished:_______ Crackles:_______ Wheezes:_______
Condition of teeth/gums:______________ Appearance of tongue:______________ 
Mucous membranes:______________
Bowel sounds (quadrant location/type):_________________________ Hernia/masses:____________________________________________
Urine S/A or Chemstix:______________________________________ 
Serum glucose (Glucometer):_________________________________
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Elimination Assessment Tool

Subjective (Reports)

 Usual bowel elimination pattern:________ Character of stool (e.g., hard, soft, liquid):________ 
Stool color (e.g., brown, black, yellow, clay colored, tarry):________
Last BM/Character of stool:________ Constipation (acute/chronic):________Diarrhea (acute/chronic):________ Bowel incontinence:________ History of bleeding:________ Hemorrhoids/fistula:________ Laxative use:_____________ How often:_____________ Enema/suppository:_____________ How often:_____________
Usual voiding pattern and character of urine:_______________________________________________________
Difficulty voiding:________ Urgency:________ Frequency:________ Retention:________ 
Bladder spasms:________
Pain/burning:_____________________________________________________________________
Urinary incontinence (type & time of day usually occurs):______________________________________________
History of kidney/bladder disease:______________________________________________________________________________________
Diuretic use:_____________________________________________ 
Other medications/herbals:_________________________________

Objective (Exhibits)
Abdomen (auscultation):________ Bowel sounds (location/type):________ Abdomen (palpation):________ Soft/firm:________ 
Tenderness/pain (quadrant location):________Distention:________ Palpable mass:________ Size/girth:________
CVA tenderness:_______________________________________________________________________________
Bladder palpable:_________________ Residual (per scan):_________________ 
Overflow voiding:__________________
Rectal sphincter tone (describe):_________________ Hemorrhoids/fistulas:_________________
Stool in rectum:_________________ Impaction:_________________ Occult blood:(+ or –):_________________
Presence/use of catheter or continence devices:________ 
Ostomy appliances (describe appliance and location):________

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Circulation Assessment Tool

Subjective (Reports)

 History of/treatment date:________High blood pressure:________ Brain injury:________ Stroke:________ 
Heart condition/surgery:________ Rheumatic fever:________
Palpitations:________Syncope:________ Pain in legs:________ Ankle/leg edema:________ 
Blood clots:________ Bleeding tendencies:________
Spinal cord injury/dysreflexia episodes (describe):____________________________________________________
Slow/delayed healing (describe):____________________________________________________________________________________
Extremities: Numbness (location):________________Tingling (location):________________
Cough (describe)/hemoptysis:_________________________________________________________
Change in frequency/amount of urine:________________________________________________________________________________________
Medications/herbals:____________________________________________________________________________

Objective (Exhibits)
Color (e.g., pale, cyanotic, jaundiced, mottled, ruddy):________ Skin:________ Mucous membranes:__________ Lips: Nailbeds:________
Conjunctiva:___________________________________________________________________________________
Skin moisture (e.g., dry, diaphoretic):______________________________________________________________
BP (R & L): Lying:________ Sitting:________ Standing:________ Pulse pressure:________ 
Auscultatory gap:________
Pulses (palpated 1–4 strength):________ Carotid:________ Temporal:________ Jugular:________ Radial:________ Femoral:________ Popliteal:________
Posttibial:_________________________________________________________ 
Dorsalis pedis:_____________________________________________________
Cardiac (palpation): Thrill:_________________________________________________________ Heaves:_______________________________________________________________________
Heart sounds (auscultation):___________ Rate:___________ Rhythm:__________ Quality:__________ 
Friction rub:__________
Murmur (describe location/sounds):___________________________________________________________
Vascular bruit (location):____________________________________________ 
Jugular vein distention:______________________________________________
Breath sounds (describe location & sounds):________________________________________________________
Extremities:________ Temperature:________ Color:________ Capillary refill (1–3 sec):________ 
Edema (+1 to +4):________ Homans sign (+ or –):________
Varicosities (location):________ Nail abnormalities:________ Distribution/quality of hair:________ 
Trophic skin changes:________
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Activity/Rest Assessment Tool

Subjective (Reports)

Occupation:________________Able to participate in usual activities/hobbies:________________________
Leisure time/diversional activities:_________________

Ambulatory:_________________Gait (describe):____________________Activity level (sedentary to very active):______________Daily exercise (type):______________________

Changes in muscle mass/tone/strength:___________________________

History of problems/limitations imposed by condition (e.g., immobility, transfer difficulties, weakness,breathlessness):_________________________________________________________________

Feelings (e.g., exhaustion, restlessness, boredom, dissatisfaction):___________________________________________________

Developmental factors (e.g., delayed/age):_____________________________________________________________________________

Sleep:___________________Hours:_____________________Naps:___________________Aids:___________
Insomnia:________________Related to:_________________

Difficulty falling asleep:________________________Difficulty staying asleep:_________________________

Rested on awakening:______________________Excessive grogginess:______________________
Bedtime rituals:___________________________

Relaxation techniques:_____________________Sleeps on more than one pillow:___________________________________

Use of oxygen (type):____________________________When used:_________________________

Medications or herbals for/affecting sleep:_________________________________________

Objective (Exhibits)
Observed response to activity: Heart rate:___________Rhythm (reg/irreg):____________
Blood pressure:______________Respiratory rate:__________

Pulse oximetry:________________________________

Mental status (e.g., cognitive impairment, withdrawn/lethargic):_____________________________

Neuromuscular assessment: Muscle mass/tone:_________________________________________
Posture (e.g., normal, stooped, curved spine):____________________________________________

Tremors (location):__________________________ROM:_____________________________

Strength:_____________________________Deformity:_______________________________

Mobility aids (list):_____________________________________________________________
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General Information Assessment Tool

General Information

 Name:______________________Age:______DOB:_____________ Gender:___________ Race:_____________

Admission Date:_________Time:___________From:________________________________________________

Reason for this visit/admission (primary concern):___________________________________________________

Source of information:__________________________Reliability (1–4 with 4 = very reliable):_________________

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