Healthcare Assessment Scales

Healthcare Assessment Scales

Patient Information

Date of Birth:

Insurance / Billing

Medical History & Current Status

Vitals / Baseline Measures

Height:   Weight:

Blood Pressure:   Pulse:

Assessment Scales — Instructions and Use

This document records standardized assessment scores used to inform clinical evaluation and care planning. Clinician must complete items in full and calculate totals where indicated. Scores become a part of the patient medical record. By signing below, the patient affirms that the information provided is accurate to the best of their knowledge and authorizes the care team to use these assessments for treatment and quality purposes.

Pain Numeric Rating Scale (0–10)

Ask patient to rate pain in the last 24 hours. Enter numeric rating below.

Interpretation: 0 = no pain; 1–3 = mild; 4–6 = moderate; 7–10 = severe.

PHQ‑9 Depression Severity

For each item, score 0 (Not at all) to 3 (Nearly every day). Enter numeric value for each item and compute total.

Score interpretation: 0–4 minimal; 5–9 mild; 10–14 moderate; 15–19 moderately severe; 20–27 severe. Clinical judgment required for treatment planning.

GAD‑7 Anxiety Scale

Score each item 0–3. Enter item scores and compute total.

Interpretation: 0–4 minimal; 5–9 mild; 10–14 moderate; 15–21 severe. Use in conjunction with clinical interview.

Mini‑Mental State Examination (Brief)

Record component scores below. This abbreviated record is intended for screening; full MMSE or other cognitive testing may be required for diagnosis.

Use age and education adjustments as clinically appropriate. Scores near cutoffs should prompt further assessment.

Braden Pressure Injury Risk Scale

Score subscales per standard definitions. Lower total indicates higher risk.

Interpretation and care plan should follow facility protocols for identified risk level. Document interventions initiated.

Fall Risk — Morse Fall Scale

Record individual item scores and compute total. Use total to guide fall prevention measures.

Clinical Notes / Summary of Findings

Privacy, Authorization & Acknowledgments

The information collected on these assessment scales is part of the medical record. Assessment scores may be used by authorized members of the care team for treatment, quality improvement, and care coordination. Scores will be maintained in accordance with applicable privacy laws and facility policy.

I acknowledge receipt of the facility privacy practices and consent to the use of assessment data for treatment and coordination of care.

I authorize the care team to share assessment results with designated healthcare providers involved in my care.

Revocation: The patient may revoke the authorization in writing at any time except to the extent that action has already been taken in reliance on it. Revocation must be submitted to the health information management department or designated facility representative.

Certification

I certify that the information provided on this form and during the assessments is true and accurate to the best of my knowledge. I understand assessment scores are used to guide clinical decisions and that I may discuss results and recommendations with my clinician.

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