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care assessment
Published By Lorraine Grote Johnson on March 21, 2019

In 2017, the U.S. Department of Health and Human Services noted that Americans turning age 65 have about a 70 percent chance of needing some type of long-term care services in their future. Long-term care services can cover both a person’s medical and nonmedical needs, helping them maintain their independence.

Depending on the functioning level of the person, long-term care services may assist with their activities of daily living (ADLs)—bathing, dressing, toileting, feeding, ambulation, grooming—and instrumental activities of daily living (IADLs)—grocery shopping, medication reminders, transportation and homemaking.

When a local Right at Home office is contacted for service, a consultation is performed to assess the care needs of the client so a custom care plan can be initiated. As state regulations and services vary, differing consultations may be considered—a personal care assessment or a skilled care assessment will be conducted by a local care team member or a professional licensed nurse (a registered nurse or licensed practical nurse).

Personal Care Assessment

When a family member of a senior contacts a home care agency requesting assistance with ADLs, IADLs and/or medication reminders for their loved one, an interviewer will visit the elderly person to make a personal care assessment. This type of consultation does not require the service of a professional licensed nurse, nor includes the nursing process.

The goal of a personal care assessment is to:

  • Learn more about the client and family.
  • Conduct a visual assessment of the client to confirm the care plan is appropriate.
  • Create a care plan that includes assisting the client with ADLs and IADLs in accordance with state regulations.
  • Understand the social and emotional well-being of the client.
  • Learn about the overall physical health of the client, including a recent injury or illness, hospitalization, or diagnosis and treatment.
  • Understand the client’s general cognition and decision-making ability.
  • Conduct a visual assessment of the environment to ensure client and caregiver safety.

Skilled Care Assessment

When a physician orders an assessment or before an approved skilled care service provider delivers care to a client, a registered nurse (RN) or licensed practical nurse (LPN) (depending on the state requirement) will have to conduct an objective clinical evaluation or appraisal of an individual’s health status (including acute and chronic conditions) using the five-part nursing process—assessing, diagnosing, planning, implementing and evaluating.

A skilled care assessment gathers information about the person’s health status through the collection of data, observation and/or physical examination. Although a skilled care assessment may include elements of a nonskilled consultation (personal care assessment), it must be performed by a professional licensed nurse and include both a nursing diagnosis and treatment.

The information gathered can include but is not limited to:

  • Assessing a person’s physical and cognitive status using professional tools (e.g., mental state mini-examination).
  • Assessing a person’s physical and/or intellectual impairments—speech/hearing/vision, paralysis, balance, motor function.
  • Assessing a person’s vital signs to determine their current physical state, reporting abnormal readings to the physician, obtaining orders from the physician and implementing them, and evaluating the effectiveness of the orders.
  • Identifying measurements that may be abnormal and recommending a care plan based on those findings.
  • Assessing current medication compliance using the five “rights” of medication administration:
    • Right patient
    • Right drug
    • Right route
    • Right time
    • Right dosage

This includes medication reconciliation, which is the process of comparing a client’s medication orders to all of the medications the client has been taking. The nurse then coordinates with the physician on changes to current medications.

Once the nurse has completed the full assessment, a care plan for the person will be formulated.

Example of a Skilled Care Assessment

Following is an example of a skilled care assessment: A client is unable to self-medicate and requires assistance with administering medications. The client’s physician refers the case to a care provider for assistance. The care provider contacts the physician for medication administration orders, which includes the five “rights” listed above.

The care provider’s licensed professional nurse reviews the client’s past medical history with the client and family and performs a clinical assessment. For example, if the nurse determines a client has fluid in the lungs, which can indicate fluid overload, but the client is not on a diuretic, the nurse will call the physician with the assessment including vital signs and medication reconciliation. The physician will then order a diuretic to be initiated and the nurse to re-check the status of the client in 24 hours and provide an update. The nurse will conduct another clinical evaluation in 24 hours to determine if the new medication is working appropriately and report back to the physician; the client will typically visit the physician’s office in two days’ time for further lab work.


About the Author

lorraine grote johnson rn bsn

Lorraine Grote Johnson, RN, BSN, joined Right at Home as Director of Care Quality with three decades of nursing experience working in various departments of a hospital and the in-home care sector.


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