Residential Care Facility Evaluation Document

Residential Care Facility Evaluation Document

Facility & Evaluation Information

Facility Name:    Address:

Evaluation Date:    Evaluator Name:

Patient / Applicant Information

Date of Birth:    Gender: Female Male Other

Phone:    Emergency Contact:    Emergency Phone:

Insurance / Payment

Policy Number:    Group Number:    Subscriber Name:

Medical History & Current Conditions

Functional Assessment (Activities of Daily Living)

For each ADL indicate level: Independent (I), Needs Assistance (A), Dependent (D)

Bathing: I A D

Dressing: I A D

Toileting: I A D

Transferring / Mobility: I A D

Feeding: I A D

Cognitive, Behavioral & Safety Risks

Cognitive Status: Alert Disoriented Memory impairment Dementia

Wandering / Elopement Risk: Yes No    Falls Risk History: Yes No

Mobility, Equipment & Nutritional Needs

Ambulation: Independent Needs assist Non-ambulatory

Assistive Devices: Cane Walker Wheelchair Hoyer lift

Psychosocial & Caregiver Support

Legal Status & Advance Directives

Power of Attorney for Health: Yes No    If yes, Name:

Do Not Resuscitate (DNR) Order Present: Yes No    Guardianship: Yes No

Assessment Summary & Recommendation

Admit — No restrictions Admit — With conditions/services specified below Not appropriate for this level of care

Skilled Nursing Assisted Living Memory Care Respite Care

Authorization to Obtain/Release Records & Certification

By signing below, I authorize the release of medical, psychiatric, and social service records necessary to complete this evaluation and to permit the facility to verify information relevant to admission. I understand that the information disclosed is protected by state and federal privacy laws and will be used solely for purposes of admission evaluation, care planning, and care delivery within the facility.

I understand that I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it. This authorization will expire on the date indicated below or one year from the date of signature if no date is provided.

Certification: I certify that the information contained in this evaluation is true and complete to the best of my knowledge. I understand that misrepresentation of material facts may affect admission decisions.

Evaluator Notes / Additional Comments

Sign Now