Nursing Treatment Continuum Assessment Form
Nursing Treatment Continuum Assessment Form: Please complete the following assessment to help us evaluate nursing treatment needs across the care continuum.
Current Care Setting
*
Home
Community Clinic
Hospital (Acute)
Rehabilitation Facility
Long-Term Care
Other
Functional Independence Level
*
Completely independent
Requires minimal assistance
Requires moderate assistance
Requires maximal assistance
Dependent
Pain Level (0 = No pain, 10 = Worst possible)
*
0
0
1
2
3
4
5
6
7
8
9
10
10
0 is 0, 10 is 10
Mobility Assessment
*
Rows
Independent
Needs Assistive Device
Needs Human Assistance
Unable
Walking
1
2
3
4
Transferring
5
6
7
8
Stair Climbing
9
10
11
12
Cognitive Status
*
Alert and oriented
Occasional confusion
Frequent confusion
Disoriented
Medication Management
*
Manages independently
Requires reminders
Needs full assistance
Support System Availability
*
Consistent daily support
Intermittent support
Minimal or no support
Risk Factors (select all that apply)
*
Recent fall
Impaired vision
Impaired hearing
Chronic illness
None
Other
Overall Treatment Priority
*
Symptom management
Functional improvement
Preventing complications
Care coordination
Additional Comments or Observations
Submit Assessment
Should be Empty: