Nursing Home Assessment Documentation

This Nursing Home Assessment Documentation serves as a comprehensive tool for evaluating residents' physical, mental, and social well-being. Please complete each section accurately to facilitate individualized care planning and ensure compliance with US nursing home standards and regulations.

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Resident Information

Name:
Date of Birth:
Gender:
Address:
Admission Date:
Physician:

Next of Kin/Contact Person

Name of Next of Kin/Contact Person:
Relationship:
Contact Information:

Assessment Details

Physical Health Assessment
Vital Signs:	Blood Pressure: Heart Rate: Respiratory Rate: Temperature:
Mobility Status:
Skin Integrity:
Nutrition Status:
Activities of Daily Living (ADLs):

Mental Health Assessment
Cognitive Function:
Mood and Affect:
Behavioral Observations:

Medication Management
Current Medications:
Allergies:

Social and Emotional Assessment
Social Support System:
Emotional Well-being:

Safety Assessment
Fall Risk:
Environmental Safety:
Emergency Preparedness:

Care Plan

Based on the assessment findings, the following care plan is recommended:

Follow-Up Plan

Regular Follow-Up Assessments:
Consultations with Specialists:
Family Meetings:

Signature Section

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