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Appendices<br />

3. Safety<br />

List Any Assessment Tools In Use andTheir Scores<br />

MNA_______________________________________________________________<br />

Barthel______________________________________________________________<br />

FRASE_____________________________________________________________<br />

Other_______________________________________________________________<br />

(4a) Waterlow_______________________________________________________________________<br />

Pressure area description_______________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

Pressure area maintenance plan_________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

Repositioning_______________________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

Agreed Short-Term Goals<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

__________________________________________________________________________________<br />

Agreed Long-Term Goals<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

Additional Comments<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

__________________________________________________________________________________<br />

Review Comments<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

Signature: _____________________________ Date:_______________<br />

Review Signature: _______________________Date:_______________<br />

Review Signature: _______________________Date:_______________<br />

Review Signature: _______________________Date:_______________<br />

Review Signature: _______________________Date:_______________<br />

391

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