ADL Facility Assessment Checklists - Kansas Foundation for ...

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Checklist: ADL Assessment (Cont.)4. Neuro-musculoskeletal:a. ROMb. Strengthc. Coordinationd. Loss of Balancee. Dizzinessf. History of fallsg. Sensation (touch, temperature, proprioception)h. Edemai. Vision, hearingj. Communicationk. Other (describe)5. Use of adaptive/assistive equipment:a. Orthosesb. ProsthesesYesc. OtherY N6. Pain Y N7. Communication ability Y N8. Cognition, alertness, orientation, safety awareness Y N9. Other health conditions & components that mayinfluence ADL functiona. Adverse drug reactionb. Total number of medications >3c. Aspirationd. Depressione. Deliriumf. Psychosisg. Fluid, electrolyte imbalanceh. Nutritional deficitsi. Skin breakdownj. Use of restraintsYYYYYYYYYYYYYYYYYYYYYYYNoNNNNNNNNNNNNNNNNNNNNNNNPersonResponsible:Comments:
Checklist: ADL Assessment (Cont.)10. Environmental factors:a. FurnitureYesb. Building (configuration, size of room)Y Nc. OtherY N11. Family Support, caregiver involvement Y N12. Customs, religious beliefs that may affect healthcare Y N13. Ability to learn:YNoNPersonResponsible:Comments:a. Barriers to participation/learning (vision, hearing,language, comprehension, memory, depression,interest…)b. Preferred learning style14. Current treatment interventionsa. Frequency, duration, time of dayb. Response to treatments15. Need to refer resident to other health professionalfor management of health components outside yourprofessional scope of practice?16. Follow-up recommendations:a. Revise current ADL goals, plan of careb. Refer to therapy for comprehensive assessmentc. Recommend equip, environmental modifications,etc.d. Initiate ADL/restorative programe. Continue current restorative programf. Discharge from ADL/restorative programg. Other (describe)YYYYYYYYYYYYNNNNNNNNNNNNIf any of the above elements in your process are missing:• Choose one element to focus your quality improvement effort on first.• Start with the Quality Improvement Worksheet A: Identifying Areas for Improvement to collect datato investigate further.• Follow the Quality Improvement Worksheets to implement missing element(s) and monitor regularlyto determine whether implementation is successful.If none of the above elements are missing from your facility’s processes, please continue to the nextchecklist.
Page 1 and 2: ADL Decline: Program ChecklistsThis
Page 3: Checklist: ADL AssessmentIf your fa
Page 7 and 8: Checklist: ADL Care Plans (Cont.)If
Page 9 and 10: Checklist: Monitoring and Reassessi
Page 11: 6. Is there a designated clinical

ADL Facility Assessment Checklists - Kansas Foundation for ...

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