Record whether the client is currently receiving assistance or supervision of another person with using public transport, getting to and from places away from home, and driving. Include assistance organised, provided or delivered by agencies (formal support) or assistance that is provided by family, friends or neighbours (carers) (informal support). Record details relating to the support received, such as: Who provides the support What support is provided The period of time the client has received the support for. Considerations for best practice Context: This refers to how the client is completing the functionality activity. Consider/record: Using a strengths-based approach to assessment, identify what steps a client can and wants to do within a functional activity, rather than only what they have difficulty with. Record whether the client is currently receiving assistance or supervision of another person with this activity. Include assistance organised, provided or delivered by agencies (formal support) or assistance that is provided by family, friends or neighbours (carers) (informal support). Summary of Function Summary of Function Response options Text (maximum 1000 characters) Business rules Mandatory. Assessment level Home Support Assessment Comprehensive Assessment Pre-population Add in Support Plan Assessment Summary Help text A holistic summary of: The client's level of function. The impact on activities of daily living. Any unmet needs.
Help text Whether the client has any major skin conditions. Details Response options Text (maximum 500 characters) Business rules Mandatory if ‘’ = Yes. Assessment Home Support Assessment Comprehensive Assessment Pre-population Add in Support Plan Assessment Summary Help text Consider and record: The skin condition(s) the client has and their impact on functioning. Whether the skin condition(s) require treatment, how frequently, and how it is currently being managed. Whether a referral is required for nursing/wound management. Considerations for best practice Context: This refers to whether the client has any skin conditions. Skin is a person’s protective layer. During the ageing process the skin thins and loses elasticity and moisture and is more easily susceptible to injury such as tears, ulcers and dryness. Nutrition, mobility, cognition, falls, pain management and continence are vital to healthy skin integrity. Clients may not consider skin conditions as potential issues. Therefore, observation at assessment is important. Consider/record: The type of skin condition experienced. Pressure ulcer: Signs that a pressure ulcer is beginning to form may include colour changes, temperature changes, changes in consistency of skin or changes in sensation. skin ulcer: Signs of other skin ulcers include open craters, often round, red, swollen and tender to touch. These can appear anywhere on the body and can be caused by a number of factors including circulatory impairment. Healing surgical wounds: of surgical wounds include the presence of dressings and stitches. The assessor should ask the client if they are being medically treated. day
Assessment level Home Support Assessment Comprehensive Assessment Pre-population Add in Support Plan Assessment Summary Help text Consider and record: How many cigarettes the client smokes, and how frequently The impact of tobacco use (such as on medication use, physical health and medical history, functional abilities, psychological wellbeing and age) Whether tobacco use is causing problems for the client Whether the client wishes to quit smoking Relevant history relating to tobacco use. Considerations for best practice Context: This refers to whether the client currently smokes daily or frequently. According to health experts, smoking affects all body organs and functions. It contributes to diseases such as cancer, heart disease and respiratory disease and it may also affect cognitive functioning. Consider/record: Whether the client currently smokes The number of cigarettes the client states they smoke per day Whether the client wishes to quit smoking If the client has previously smoked, record when they ceased smoking. Recommendations: Recommendation/referral to Quit Smoking program.
The following equipment is required to administer the instrument: A watch, a pencil, reverse of the SMMSE score sheet with CLOSE YOUR EYES written in large letters and two five-sided figures intersecting to make a four-sided figure, and a space for the person to write down a sentence. Rowland Universal Dementia Assessment Scale Rowland Universal Dementia Assessment Response options • Yes • No Business rules Select one option. Assessment level Home Support Assessment Comprehensive Assessment Pre-population Add in Support Plan Assessment Summary Help text A short cognitive screening instrument designed to minimize the effects of cultural learning and language diversity on the assessment of baseline cognitive performance. When administering the RUDAS it is important that the respondent is encouraged to communicate in the language with which they are most competent and comfortable. Considerations for best practice Context: The Rowland Universal Dementia Assessment Scale (RUDAS) is a short cognitive screening instrument designed to minimise the effects of cultural learning and language diversity on the assessment of baseline cognitive performance. Instructions and interpretation: General Guidelines for the Administration: Test Anxiety: Make sure the client is as relaxed as possible, as test anxiety can interfere with performance on cognitive tests. Hearing: Conduct the in a quiet area and make sure the client can hear clearly. It is important to identify at the beginning of the assessment if the client has impaired hearing and accommodate for this as much as possible by speaking slowly and clearly. Encourage the client to wear any hearing aids. Be careful not to speak too loudly as this may result in distortion. There is a large print version of the RUDAS for clients with severe hearing impairment. Vision: Ensure that the client is using reading glasses where necessary and that there is sufficient light in the room. Seating: Sit opposite the client. This is important for communication reasons as well as for controlling the difficulty of some items on the RUDAS. Do not sit behind a desk,
Psychological Domain – Psychosocial Introoduction The Psychosocial section relates to the client’s mental health and social wellbeing. It seeks information on feelings of nervousness or depression; and feelings of loneliness or social isolation. Feelings of nervousness or depression Feelings of nervousness or depression Response options • Yes • No Business rules Mandatory. Select one option. Assessment level Home Support Assessment Comprehensive Assessment Pre-population Add in Support Plan Assessment Summary Help text Whether the client has recently (i.e. within the last four weeks) had feelings of nervousness or depression. Type Response options Business rules If ‘’ = Yes, select one or multiple. Assessment level Home Support Assessment Comprehensive Assessment Pre-population Add in Support Plan Assessment Summary Help text See . Details Response options Text (maximum 500 characters) Business rules Mandatory if ‘’ = Yes. Assessment level Home Support Assessment Comprehensive Assessment Pre-population Add in Support Plan Assessment Summary Help text Consider and record: The feelings of nervousness experienced by the client (e.g. feeling anxious, worried, edgy, panicky, uneasy) The feelings of depression experienced by the client (e.g. feeling unhappy, ‘blue’, down, miserable, dejected, low, disheartened, sad).
0604 Parkinson’s disease (includes Parkinson’s disease, secondary Parkinsonism) 0605 Transient cerebral ischaemic attacks (T.I.A.s) 0606 disease/disorders (includes senile degeneration of brain n.e.c, degeneration of nervous system due to alcohol, Schilder’s disease) 0607 Multiple sclerosis 0608 Epilepsy (includes seizures) 0609 Muscular dystrophy 0610 Cerebral palsy 0611 Paralysis—non-traumatic (includes hemiplegia, paraplegia, quadriplegia, tetraplegia & other paralytic syndromes, e.g. diplegia & monoplegia; excludes spinal cord injury code1699) 0612 Chronic/post-viral fatigue syndrome 0613 Shingles (Zoster) and/or postherpetic neuralgia 0614 Peripheral Neuropathy 0615 Normal pressure hydrocephalus 0699 Other diseases of the nervous system n.o.s or n.e.c (includes dystonia, migraines, headache syndromes, sleep disorders e.g. sleep apnoea & insomnia, Bell’s palsy, myopathies, dysautonomia, progressive supranuclear palsy, restless legs syndrome) Diseases of the eye & adnexa 0701 Cataracts 0702 Glaucoma 0703 Blindness (both eyes, one eye, one eye & low vision in other eye) 0704 Poor vision (low vision both eyes, one eye, unspecified visual loss) 0705 Macular degeneration 0799 Other diseases of the eye & adnexa n.o.s or n.e.c (includes conjunctivitis, dry eyes) Disease of the ear & mastoid process 0801 Ménière’s disease (includes Ménière’s syndrome, vertigo) 0802 Deafness/hearing loss 0899 Other diseases of the ear & mastoid process n.o.s or n.e.c (includes disease of external ear, otitis media, mastoiditis and related conditions, myringitis, otosclerosis, tinnitus) Diseases of the circulatory system 0900 Heart disease 0901 Rheumatic fever 0902 Rheumatic heart disease
Appendix C The follow fields will be pre-populated in to the assessment summary. Location Profile Field Assessment summary location Client Record Title Introduction name All sections Last name Introduction Estimated age Introduction Lives with Background Accommodation type Background Services in place Background Current care approvals Recommendations Assessment Assessment Details Introduction Introduction Introduction Introduction Reason for Assessment Introduction Carer Background Background Background Sustainability of Caring Relationships Assessment Function Assessment Health conditions Situation Assessment Cognition Home Support Assessment only Assessment Home Support Assessment only Assessment Psychological Comprehensive Assessment only Assessment Support Plan Review Recommendations Recommendations