Personal Details

Your Personal Details

Full Name inc. Title:

Date of Birth:

How would you like to be addressed:

Current Address:

Contact Telephone Number:

Preferred Language:

Do you require a Translator?

Religion / Beliefs:

Next of Kin Details

Name:

Relationship to you:

Address:

Home Telephone Number:

Work Telephone Number:

Mobile Telephone Number:

Emergency Contact Details - (if different from Next Of Kin)

Are they the same as 'Next of Kin'?

SEE NEXT OF KIN DETAILS

Name:

Relationship to you:

Primary Contact Number:

Secondary Contact Number:

GP Details

GP Name:

Surgery Name:

Surgery Address:

Telephone Number:

Out of Hours Telephone Number:

Care Manager / Social Worker Details

Name:

Address:

Office Telephone:

Out of Hours Telephone:

Funding Details
Date Paperwork Received:
Social Services Review Date:

Funding Sources:

Total Care / Support Hours Required:

Existing Support

What Existing Care / Support do you Currently Receive? Details of any Existing Care / Support you currently receive: (name of person/organisation - contact details inc address - type of Care/ Support and days/times)

About You and Your Life History

About You and Your Life History - Note: Consider things such as Birth Place, Growing Up, Work, Family, Relationships, Significant Dates, Interests/Hobbies, TV Programs, Books/Papers, Food & Drink likes/Dislikes):

Medical and Medication

Medical and Medication Information

Known Allergies

Medical History

Does the Service User take Medication?

Current Types of Medication (Consideration MUST be given to the type of Medication and level of Staff Interaction as some Medication Types and Administration Methods will require 'Specialist Training')

List ALL Current Medications: (see MAR Sheet for details etc.)

Medication Dispensing:

Does the Service User Self Medicate?

Complete a 'Medication Self Assessment' form

Are Staff Required To have involvement with Service User Medication?

What Level of Input will be required by Staff?

Does any Medication Assistance require Staff to have 'Specialist Training'?

Specialist Training Requirements:

Are there any 'Special' Training Requirements as per Local Authority?

Local Authority Requirements:

Is a MAR Chart in Place and Ready for use?

ARRANGE FOR MAR CHART BEFORE COMPLETING THIS SECTION

Difficulties taking Medication e.g. Swallowing, Spilling Liquid Meds etc?

Details of any Difficulties:

Does Management of Prescribed or Un-Prescribed Medication(s) have 'Potential' to Cause Risk?

Details of any Potential Risks:

Is All Appropriate Documentation On File? e.g. MAR Sheets, Controlled Drugs Records, Disposal Forms etc.

Details of requirements:

Are there any 'Controlled Drugs'?

Are they Adequately Stored?

Details of Storage Improvement Requirements:

Is a 'Consent to Treatment' Form required? (Mental Health)

COMPLETE A 'CONSENT TO TREATMENT' FORM BEFORE COMPLETING THIS SECTION

Any Relevant Notes or Information:

Skin Care

Skin Care and Pressure Care

Are there any Skin Care Concerns at this time?

Skin Care Products to use:

Skin Care Routine:

CLEARLY IDENTIFY ON BODY CHART

Select Chart

Complete Chart when Printed

Male

Complete Chart when Printed

Female

Any Relevant Notes or Information:

Pressure Care Concerns

Are there any Pressure Care issues at this time?

Pressure Care Aids:

Pressure Care Routine:

CLEARLY IDENTIFY ON BODY CHART

Select Chart

Complete Chart when Printed

Male

Complete Chart when Printed

Female

Any Relevant Notes or Information:

Turns Monitoring requirements

Is a 'Turns Monitoring' Form Required?

Completed and included with the Care Plan?

Any Relevant Notes or Information:

Sight - Hearing - Communication

Communication
Service Users Levels of Verbal Communication and Conversation are:

Do they Respond Well to YES / NO Type Questions?

What other types of Communication can be used? (Picture/Note Pad/Sign etc)

Any Relevant Notes or Information:

Sight

Service Users Sight is:

Does the Service User Wear Glasses?

Glasses required:

Other Relevant Information: (contact lenses etc)

Any Relevant Notes or Information:

Hearing

Service Users Hearing is:

Is a Hearing Aid or Hearing Device Used?

Details of Devices Used by Service User:

Any Relevant Notes or Information:

Mobility and Dexterity

Mobility and Dexterity

Able to Walk Unaided?

Requires the use of the following items:

Details of Other Equipment or Device:

Is there a Risk relating to any of the Mobility Aids?

COMPLETE A MOBILITY RISK ASSESSMENT

Able to Go Out Alone?

Will Staff be required to assist the Service User on External Activities?

Details:

Complete an 'EXTERNAL RISK ASSESSMENT' Form for all external activities

Will Staff be required to assist the Service User on External Activities?

Details:

Complete an 'EXTERNAL RISK ASSESSMENT' Form for all external activities

Has the Service User 'Fallen' in the Past 12 months?

Details:

Complete a 'Falls Risk Assessment' Form

Any Relevant Notes or Information:

Showering/Bathing/Grooming

Personal Hygiene Routines
Showering / Bathing
Service User Prefers:

Details:

Service User is:

Bathing Risk Assessment Completed?

Details of Preferred Frequency & Day / Time:

Showering / Bathing Aids:

Details of Other:

Details of Preferred Toiletries:

Any Relevant Notes or Information:

Hair Care
Service User is:

Hair Dresser Frequency and Details:

Facial Hair

Service User Prefers:

Details of Other:

Shaving Frequency and Details:

Details of any Other Hair Removal Requirements:

Any Relevant Notes or Information:

Oral Hygiene Routine

Own Teeth:

Details of Teeth:

Dentures:

Details of Dentures:

At Night, Dentures are to be:

Any Relevant Notes or Information:

Foot Care
Service User is:

Details of Foot Care Routines & Specialist Treatment:

Any Relevant Notes or Information:

Dressing / Undressing

Dressing and Undressing Requirements

Service User is:

Details of All Assistance Required:

Any Relevant Notes or Information:

Continence Needs

Bladder Management

Service User is:

Toileting Regime:
Toileting Aids:
Management Aids:

Catheter Management Plan:

Details:

Details of Specific Toilet Times / Routines:

Any Relevant Notes or Information:

Bowel Management

Service User is:

Management Aids:

Details of Incontinence:

Details of Specific Toilet Times / Routines:

Any Relevant Notes or Information:

Eating and Drinking

Eating and Drinking Requirements

Are there any Enteral (PEG/NGT) Feeding Requirements?

Give detailed information as to requirements:

Prefers to have Meals in:

Details:

For Eating, the Service User is:

Service User is:

Requires a 'Special diet'?

Type of Diet is:

Are there any foods the Service User SHOULD NOT Consume?

Give full details of food items the Service User may not consume and reasons why:

Is there a requirement for and specific Eating Aids?

Give Full Details:

For Drinking, the Service User is:

Do they have a 'Preferred' drink?

Details of Drinks:

Is there a requirement to use a 'Thickener' ?

Details of Thickener required:

Are any 'Drinking Aids' required?

Give Details of Drinking Aids:

Sleeping and Settling

Sleeping and Settling Requirements
Usual Time to Rise:
Usual Time to Bed:

Daytime Rest Routine:

Preferred Sleeping Position:

Preferences for Bed Coverings / Pillows etc.

Sleeping Aids:

Sleeping Aids Details:

Room Preferences:

Night Time Patterns:(e.g. Wanders/Talks/Shouts etc.)

Details of any Night Time Checks Required:

Finances

Finances

Does the Service User manage their own finances

Contact details for Finance Management:

Have they made any Advanced Decisions?

Contact details of responsible Person:

Have they prepared a Will?

Contact details of responsible Person:

Risk Assessment

General and Physical Health

Do you have any General or Physical Health Considerations?

Details:

Do the above considerations have the potential to cause Risk?

Details:

Is there a Risk of Injury from Slips and Falls?

Details:

Falls Risk Assessment

Age:

Mobility:

History of Falls?

Sensory Impairment?

Other Factors

Medication Side-Effects?

Loss of Sensation?

Oedema Lower Limbs?

Shortness of Breath?

Dizziness or Light-headedness?

Pain?

Muscle Wastage or Weakness?

Incontinence and tries to Rush to toilet?

Problems with Balance?

Confusion or Aggression?

Poor Fitting Footwear?

Wanderer?

Trip Hazards around the Home?

Select Total Score:

Is the score LOWER than 14?

Service User is LOW RISK - NO Management Plan required at this time

Is the Score LOWER than 8?

Service Users with a Score of 8 or Below ARE AT HIGH RISK..!!!
Review Care Plan provision and consider the person to be HIGH DEPENDENCY
Review Staffing input requirement.

Complete a Falls Risk Management Plan for a HIGH RISK Service User

Service Users with a Score of 13 or Below ARE AT MEDIUM RISK..!!
Their Condition and Care Plan should be Monitored Closely and staff should ensure that the person has all necessary personal items close to hand to minimise risk.

Complete a Falls Risk Management Plan for MEDIUM RISK Service User.

Select date
Staff Member Completing Risk Assessment:

Is there a Risk Relating to Mobility Aids?

Complete a MOBILITY AID RISK ASSESSMENT

Is there a Requirement for a Moving & Handling Assessment?

Complete a MOVING & HANDLING RISK ASSESSMENT

Is there a Requirement to Assist with Bathing & Showering?

Complete a BATHING & SHOWERING RISK ASSESSMENT

Is there a Risk from Smoking?

Complete a SMOKING RISK ASSESSMENT

Is there a Requirement for an 'External Activities' Risk Assessment?

Complete an EXTERNAL ACTIVITIES RISK ASSESSMENT

Any relevant Notes or Information:

Mental Health & Emotional Wellbeing

Do you have any Mental Health considerations?

Do identified Mental Health considerations have a potential to cause Risk?

Details of the Risks:

Who is likely to be at Risk?

Complete a 'Triggers & Precipitating Factors' Form

What is the 'Level of Risk'?

Complete a 'Risk Management Plan'

Do you have any Emotional Wellbeing considerations?

Do identified Emotional Wellbeing considerations have a potential to cause Risk?

Details of the Risks:

Who is likely to be at Risk?

What is the 'Level of Risk'

Complete a 'Risk Management Plan'

Complete a 'Triggers & Precipitating Factors' Form

Are there any Risk of the Service User 'Wandering'?

Details:

What is the 'Level of Risk'?

Complete a 'Risk Management Plan'

Considerations on the use of Bedrails

Is there a likelihood of Falling Out of Bed?

Consider the use of Bedrails after using the Risk Matrix Tool

Would the Service User feel 'Anxiuos' if they DID NOT have Bedrails?

Consider the use of Bedrails after using the Risk Matrix Tool

Are Bedrails Likely to Reduce Independence?

Consider the Safety aspect of use after using the Risk Matrix Tool

Bedrail Safety

Are Bedrails to be used?

Is there a likelihood that the Service User may 'Climb Over' the rails?

Complete a Risk Management Plan

Is the Bed and Mattress suitable for the Rails?

Arrange for suitable equipment before using bedrails

Are there any 'GAPS' between the rail and any part of the bed that the Service User could potentially 'Trap' parts of their body?

Arrange for suitable equipment before using rails

Are the Bedrails in good condition?

Details:

Arrange for Rails to be Serviced / Replaced

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.