Step 1 Assessment: Medical Record Information
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1 Step 1 Assessment: Medical Record Information RESIDENT S NAME RESIDENT IDENTIFICATION NUMBER _ STAFF INITIALS PART A. DEMOGRAPHIC INFORMATION 1. MEDICAL RECORD ABSTRACTION DATE // 2. RESIDENT BIRTHDATE // 3. ADMISSION DATE to SKILLED NURSING FACILITY/UNIT // 4. SEX Male Female 5. HEIGHT (inches) inches 6. TUBE FEEDING No Yes IF YES, is tube-feeding: Supplemented by Oral Sole feeding method IF YES, Calories per cc Cc per day 7. ORAL NUTRITIONAL SUPPLEMENT (e.g., Ensure, Resource) No Yes IF YES, Calories per cc Cc per day 8. SPECIAL DIET No (Regular) Yes IF YES, Type of Diet (circle all the apply) No Added Salt (NAS) No Concentrated Sugar (NCS) Mechanical-Soft Pureed Small Portions Other (specify): 9. DENTURES No Yes 10. DATE OF MOST RECENT ORAL/DENTAL EXAM // mm dd yyyy
2 PART B. MEDICAL AND PSYCHIATRIC DIAGNOSES HIV AIDS CANCER CHRONIC OBSTRUCTIVE PULMONARY DISEASE CHRONIC RENAL FAILURE CONGESTIVE HEART FAILURE DEMENTIA DEPRESSION DIABETES DYSPHAGIA FAILURE TO THRIVE GASTROINSTESTINAL DISORDERS GI Bleeding Diarrhea Constipation RECURRENT ASPIRATION PNEUMONIAS RHEUMATOID ARTHRITIS WEIGHT LOSS MALNUTRITION Check ALL that Apply
3 PART C. ROUTINE MEDICATIONS with Appetite Suppressant Side Effects Generic Name / Brand Name Check ALL that Apply AMLODIPINE / NORVASC * CONJUGATED ESTROGENS / PREMARIN * DIGOXIN / LANOXIN * ENALAPRIL MALEATE / VASOTEC * FAMOTIDINE / PEPCID * FENTANYL TRANSDERMAL SYSTEM / DURAGESIC * FUROSEMIDE / FUROSEMIDE IPRATROPIUM BROMIDE / ATROVENT LEVOTHYROXINE SODIUM / SYNTHROID / LEVOTHROID METFORMIN / GLUCOPHAGE NIFEDIPINE / PROCARDIA XL * NIZATIDINE / AXID * OMEPRAZOLE / PRILOSEC * PAROXETINE HCI / PAXIL * PHENYTOIN / DILANTIN * POTASSIUM REPLACEMENT / K-DUR RANITIDINE HCI / ZANTAC * RISPERIDONE / RISPERDAL * SERTRALINE HCI / ZOLOFT * WARFARIN / COUMADIN *May be Amenable to Substitution ROUTINE MEDICATIONS to Stimulate Appetite Generic Name / Brand Name (Check ALL that Apply) CYPROHEPTADINE / PERI-ACTIN DRONABINOL MEGACE ACETATE MIRTAZEPINE / REMERON TESTOSTERONE (ANDRO-GEL OR INJECTIONS) NOTE: These medications are not necessarily appropriate or recommended for use among nursing home residents. Please consult Primary Care Physician.
4 PART D. RECENT LABORATORY VALUES RELEVANT TO NUTRITION VALUE NORMAL RANGE DATE OF MOST RECENT NONE IN LAST MONTH BUN: mg/dl (10-30) // Cholesterol:mg/dL (<200) // Creatinine: mg/dl ( ) // Serum Albumin: g/dl ( ) // Serum Osmolality: osm ( ) // Serum Sodium: meq/l ( ) // TSH: uiu/ml ( ) // T4: uiu/ml ( ) //
5 PART E. CURRENT WEIGHT AND WEIGHT CHANGE HISTORY Date of Most Recent Weight: LATEST WEIGHT (pounds/date) // lbs. WEIGHTS FOR 12 MONTHS PRIOR TO MOST RECENT WEIGHT OR ADMISSION Date Weight (pounds) // // // // // // // // // // // //
6 PART F. PHYSICAL AND COGNITIVE ABILITIES EATING DEPENDENCY: (in last 7 days) (0-4) 0=Independent (No help or staff oversight OR staff help/oversight provided only 1-2 times for resident to eat) 1= Supervision (Oversight, encouragement, or cueing provided 3 or more times OR supervision + physical assistance provided only 1-2 times) 2=Limited Assistance (Physical help in guided maneuvering to eat 3 or more times OR limited assistance + more help to eat provided only 1-2 times) 3=Extensive Assistance (full staff assistance provided 3 or more times for resident to eat) 4=Total Dependence (full staff assistance provided to resident for eating during entire seven day period) COGNITIVE ABILITY: RECALL Check all that Resident was Able to Accurately Recall (in last 7 days): a. Current Season: b. Location of Own Room: c. Staff names and/or faces: d. He/she is in a nursing home : OR e. None of the Above: IF 2 OR MORE OF ITEMS a-d ARE CHECKED, PROCEED TO RESIDENT INTERVIEWS Simmons Nutrition Software Medical Record and MDS Information (nutritionmedical.doc) Version2 (12/26/02)
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