Hospice RN Case Manager Assessment
Comprehensive intake assessment for hospice RN case management.
Patient's Primary Diagnosis
*
Current Level of Pain
*
1
2
3
4
5
6
7
8
9
10
Functional Status Assessment
*
Rows
Independent
Needs Assistance
Dependent
Mobility
1
2
3
Feeding
4
5
6
Toileting
7
8
9
Dressing
10
11
12
Cognitive Status
*
Alert
Confused
Unresponsive
Symptom Severity (Past 24 Hours)
*
Rows
None
Mild
Moderate
Severe
Shortness of Breath
13
14
15
16
Nausea
17
18
19
20
Anxiety
21
22
23
24
Restlessness
25
26
27
28
Support System Availability
*
Family present
Professional caregiver
Lives alone
Emotional State (Likert Scale)
*
Calm
1
2
3
4
Distressed
5
1 is Calm, 5 is Distressed
RN Observations/Notes
Immediate Nursing Interventions Required?
*
Yes
No
Recommended Follow-Up Actions
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