Free Nursing Home Assessment Documentation Template
Nursing Home Assessment Documentation
This Nursing Home Assessment Documentation serves as a comprehensive tool for evaluating residents' physical, mental, and social well-being. Please complete each section accurately to facilitate individualized care planning and ensure compliance with US nursing home standards and regulations.
[Month, Day, Year]
Resident Information
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Name: |
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Date of Birth: |
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Gender: |
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Address: |
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Admission Date: |
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Physician: |
Next of Kin/Contact Person
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Name of Next of Kin/Contact Person: |
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Relationship: |
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Contact Information: |
Assessment Details
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Physical Health Assessment |
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Vital Signs: |
Blood Pressure: Heart Rate: Respiratory Rate: Temperature: |
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Mobility Status: |
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Skin Integrity: |
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Nutrition Status: |
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Activities of Daily Living (ADLs): |
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Mental Health Assessment |
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Cognitive Function: |
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Mood and Affect: |
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Behavioral Observations: |
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Medication Management |
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Current Medications: |
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Allergies: |
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Social and Emotional Assessment |
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Social Support System: |
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Emotional Well-being: |
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Safety Assessment |
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Fall Risk: |
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Environmental Safety: |
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Emergency Preparedness: |
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Care Plan
Based on the assessment findings, the following care plan is recommended:
Follow-Up Plan
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Regular Follow-Up Assessments: |
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Consultations with Specialists: |
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Family Meetings: |
Signature Section
[Month, Day, Year]
[Month, Day, Year]
