Free Nursing Home Psychosocial Assessment

Address comprehensive well-being with the Nursing Home Psychosocial Assessment Template from Template.net. This editable and customizable template enables detailed evaluation of residents' psychological and social needs, contributing to holistic care planning. Editable in our Ai Editor Tool, it's crucial for understanding individual resident backgrounds, preferences, and challenges, supporting their mental and emotional health in your nursing home environment.

Resident Information
Name:
Date of Birth:
Gender:
Date of Admission:
Room Number:
Medical Record Number:
Date of Assessment:

Section I: Identifying Information
Primary Language:
Marital Status:
Living Arrangements Before Admission:
Religion/Spiritual Preference:
Ethnicity/Race:
Occupation:

Section II: Medical History
Primary Diagnosis:
Other Medical Diagnoses/Conditions:
Allergies:
Current Medications:
Physician Information:

Section III: Social History
Family/Support System:
Living Situation Prior to Admission:
Educational Background:
Military Service:
Hobbies/Interests:
Financial Resources:

Section IV: Psychosocial Assessment
Mental Health History:
Cognitive Status:
Emotional Status:
Behavioral Observations:
Socialization Skills:
Support System:
Stressors/Concerns:
Coping Mechanisms:
Goals/Desires:

Free Nursing Home Psychosocial Assessment

Section VII: Signatures

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Assessment Information
Assessment Completed By:
Relationship to Resident:

Section V: Environmental Assessment
Physical Environment:
Safety Concerns:
Accessibility:

Section VI: Recommendations/Plan of Care
Social Services Interventions:
Interdisciplinary Team Involvement:
Referrals:
Goals:
Plan of Action: