Example of a Case Management Admission Assessment Form
July 1, 2018 4 minutes read
The following categories should be included and can be used to format your own case management admission assessment form:
Patient Information:
• Patient demographic information
Admission Information:
• Admission information including:
- Admit date
- Admit diagnosis
- Admitting service
- Attending physician
- Admit source
Financial Information:
• Financial information:
- Insurance
- Plan number
- Medicaid eligibility
Spoken Language(s)
Source of Admission:
• Admitted from:
- Acute rehab
- Ambulatory surgery
- Another acute care facility
- Behavioral health
- Emergency department
- Home
- Home with home care
- Long-term care
- MD office or clinic
- Sub-acute
Significant prior medical history:
- Angioplasty
- Behavioral health
- Substance abuse
- Blindness
- Coronary artery bypass graft
- Coronary artery disease
- Cancer
- Cardiomyopathy
- Congestive heart failure
- Chronic obstructive pulmonary disease
- Deafness
- HIV / AIDS
- Hypertension
- Pacemaker
- Paraplegic
- Quadriplegic
- Renal failure
- Stroke
- Vent dependent
- Other
- None
Mental status prior to admission:
- Alert
- Not alert
- Confused
- Oriented x 1
- Oriented x 2
- Oriented x 3
Ability to make needs known:
- Able
- Unable
Living arrangements:
- Adult home
- Apartment
- Assisted living
- Group home
- Homeless
- House
- Naturally occurring retirement community
- Nursing home
- Shelter
- Stairs
- Elevator
- Other
• Lives:
- With adult children
- With dependent children
- Alone
- With other family
- With spouse/significant other
- Domestic partner
- Other
• Support system:
- Name
- Phone number
- Relationship
• Can patient return to prior living arrangements?
- Yes
- No
Activities of daily living:
- Dependent
- Independent
• Assistive device:
- Yes
- No
• Which assistive device:
- Cane
- Oxygen
- Walker
- Other
Prior resource use:
- Children’s services
- Adult services
- Adult day care
- Behavioral health services
- Dialysis center
- Home healthcare services
- Infusion therapy
- Meals on Wheels
- Medication assistance program
- Nonmedical home care
- Support group
- Health home
- Medical home
- House calls
- Other
- None
Does patient have a primary care provider?
- No
- Yes
PCP Name
Address
Phone number
Social Work triggers:
- Abuse — Domestic violence
- Abuse and/or neglect of a child
- Abuse and/or neglect of elder/Adult
- Abuse — sexual assault
- Adjustment to illness/difficulty coping
- Alcohol abuse
- Behavioral management problems
- Crime victim
- Cultural and/or language issues
- Drug abuse
- Ethical concerns
- Family concerns and/or conflicts
- Guardianship
- Homeless requesting intervention
- Hospice placement
- Inadequate social support
- Inadequate financial support
- Long-term care placement
- Major illness causing lifestyle change
- Multisystem trauma
- Name of patient unknown
- Noncompliance issues
- Poor prognosis
- Shelter placement
- Uninsured
- Undocumented
- Other
- None
• Referred to social work:
- No
- Yes
Name
Contact info
Home care triggers:
• Patients requiring assessments/education relating to:
- New diagnosis
- New medications or change in medications
• Change in patient’s physical environment and/or new assistive device
• Patients with unstable disease process; cardio/pulmonary, diabetes, neurological, neuromuscular, metabolic, cerebrovascular, cardiovascular, renal, cancer, pediatric/including asthma, premature infants, psychiatric
• Patients with open wounds, VAC wound care, pressure ulcers
• Patients with ostomy, trachs, feeding tubes
• Patients with drainage tubes and catheters
• Patients requiring IV and injectable drug therapies
• Patients with recent change in functional status including, but not limited to: falls, paralysis, fractures, amputation or other physical impairment, change in custodial needs, ortho, neuro and or deconditioned diagnosis
• Patients with pain control management
• Patients with end-stage disease and palliative care needs
• Patients with new oxygen and/or nebulizer treatments
• Patients receiving any type of home care services (e.g., CHHA, LTHHCP, PCA, private care, etc.) at time of hospital admission
• Patients rehospitalized within 60 days and/or known history of repeated hospital readmissions
• Patients requiring expedited discharges (EHD/Bridge Program)
These categories should be included and can be used to format a case management admission assessment form.
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