Barton Creek Assisted Living Type 1 & 2

Resident Assessment
Physician Evaluation

Resident Name: ___________________________________ DOB: ____/____/________

Physical Assessment

Medical/Surgical History:

Vital Signs:
 Temp. _____
 Pulse _____
 Resp. _____
 B/P _____/_____
 Weight_____

Review of Systems: (Refer to Assessment Guidelines, Page 5)

 Integumentary

 Respiratory

 Cardiovascular

 Genitourinary

 Musculoskeletal

 Neurological

 Endocrine

 Pain

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 Medication Assessment

Medication Name: Dosage: Route: Frequency:

Level of Medication Assistance Needed:

 Independent – Requires no assistance or supervision, may keep under own control
in own room.

 Needs assistance as indicated (check all that apply):

o Reminder to take
o Opening Container
o Reading instructions on container label
o Checking dosage against label
o Reassure dosage is correct
o Observe resident take medication as prescribed
o Remind resident/responsible person when prescription needs to be refilled
o Other: ______________________________________________________

Known Medication Allergies:

_______________________________________________________________________
_

Assess needed physician appointments and the person responsible to schedule, transport:
_______________________________________________________________________
_

Assess needed laboratory work, responsible person to perform and transport:

_______________________________________________________________________
_

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Assess outside health care providers e.g. independent health care professional and/or
home health agency. Identify service(s) and provider(s) with name and phone number:
_______________________________________________________________________
_______________________________________________________________________
__

Describe physical limitations:

_______________________________________________________________________
_

Describe mental limitations:

_______________________________________________________________________
_

Assess diet regimen, food allergies, preferences, and dislikes:

_______________________________________________________________________
_

Is the resident free of communicable diseases? _____ If no, please explain:

_______________________________________________________________________
_

Physician Signature: __________________________________ Date: ____/____/____

Address: _______________________________
Office Phone: (____) _____________________
Emergency #: (____) _____________________

Identify other practitioners for referral:

Dentist: _____________________________________________
Address: _______________________________
Office Phone: (____) _____________________
Emergency #: (____) _____________________

Other practitioners:

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 O.T.C. Medication Standing Orders

The Nurse at Barton Creek Assisted Living may use his/her judgment to administer over
the counter medications and treatments. If the problem or condition persists beyond
seventy-two hours, a physician will be notified and a script will be obtained. Family
members or responsible parties will be notified by the nurse if it is necessary to
implement a standing order into regular administration.

The following over the counter medications and treatments may be used per label
instructions and utilizing the above stipulations. Please initial which of the following
will become standing orders within the resident’s record.

_____ Tylenol 325 i-ii (pain, fever)

_____ Ibuprofen 200 mg i-ii (pain, fever)
_____ Milk of Magnesia 300 cc (constipation)
_____ Dulcolax suppository 10 mg (constipation)
_____ Tums (gastric distress)
_____ Immodium 2mg (diarrhea)
_____ Urinalysis (increased confusion, concentrated urine, elevated temperature,
frequent urination, burning sensation upon urination)

Patient Name: _____________________________________ DOB: ___/___/_____

RN Signature: _____________________________________ Date: ___/___/_____
Physician Signature: ________________________________ Date: ___/___/_____

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 Assessment Guidelines

Integumentary System: assessment will include skin color, skin temperature, skin
integrity, turgor and condition of mucous membranes.
Normal Findings: skin color good/within norm; skin warm/dry/intact; no skin problems:
mucous membranes moist/pink.

Respiratory System: assessment will include quality/characteristics of respiration; lung/

breath sounds; cough/sputum; color of mail beds/mucous membranes.
Normal Findings: respirations quiet/easy/regular; RR 10-20/min. at rest; breath sounds
vesicular through both lung fields; bronchial over major airways with no adventitious
sounds; no cough/sputum clear; nail beds & mucous membranes pink; no other problems.

Cardiovascular System: assessment will include peripheral pulses/apical pulse; chest

pain; edema; calf tenderness; cardiac rhythm/sound.
Normal Findings: peripheral pulses palpable, resent and strong; regular apical pulse: no
chest pain; neck vein flat/no distention; no edema; no calf tenderness; S1 and S2 audible
and regular; no other cardiac problems.

Gastrointestinal System: assessment will include appearance/palpation of abdomen;

bowel sounds; bowel pattern/stools/appetite; diet tolerance; fluid intake/weight/nausea
and vomiting.
Normal Findings: abdomen soft; bowel sounds present and active; no pain or palpation;
fair to good appetite; tolerates diet without nausea and vomiting; adequate fluid intake;
no weight loss or gain; normal bowel movement, pattern and consistency.

Musculoskeletal System: assessment will include joint swelling, tenderness ROM

limitations, muscle strength and condition of surrounding tissue.
Normal Findings: absence of joint swelling and tenderness, normal ROM on all joints; no
muscle weakness; no ADL problems; no activity or functional limitations; no evidence of
inflammation, nodules, ulcerations or rashes.

Neurological System: assessment will include orientation, pupils, movement/gait,

sensation, quality of speech/swallowing, memory, sleep pattern, seizures, vision, hearing.
Normal Findings: alert and oriented to person, place, and time; PERIL; active ROM of all
extremities with symmetry of strength; no paresthesia; no seizures; verbalization clear
and understandable, memory intact; normal gait; normal swallowing/gag reflex; regular
sleep pattern; no visual or hearing impairment.

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Endocrine System: assessment will include presence of diabetes, thyroid problems or
other endocrine dysfunctions.
Normal Findings: Absence of thyroid or endocrine problems and other endocrine
dysfunctions; no diabetes.

Pain Assessment: will include presence of pain; the resident’s description, location,
duration, intensity, radiation, precipitating factors and alleviating factors.
Normal Findings: Document if medication relieves pain.