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INITIAL ASSESSMENT AND HISTORY LONG TERM CARE Date/Time of Initial Assessment: Language(s) spoken/understood: En Fr Other: Translator requiredMode of Arrival to Site: Walking Walker Wheelchair Stretcher

How to fill out initial assessment and history

How to fill out initial assessment and history

1. Gather all necessary information about the individual's personal and medical history.
2. Begin by documenting the individual's basic demographic information, including their name, age, gender, and contact details.
3. Conduct a thorough medical interview to gather information about the individual's current health concerns and medical conditions.
4. Record information about the individual's past medical history, including any previous illnesses, surgeries, or hospitalizations.
5. Document any known allergies or adverse reactions to medications and provide appropriate details.
6. Ask about the individual's family medical history to identify any hereditary conditions that may be relevant.
7. Assess the individual's social and lifestyle factors, such as smoking, alcohol consumption, and exercise habits.
8. Capture information about the individual's current medications and supplements, including dosage and frequency.
9. Perform a comprehensive physical examination and record relevant findings.
10. Summarize the assessment findings and develop an appropriate plan of care based on the individual's needs.

Who needs initial assessment and history?

1. Initial assessment and history are necessary for any new patient or individual seeking medical or healthcare services.
2. It helps healthcare professionals to understand the individual's current health status, identify any potential risk factors or underlying conditions, and develop appropriate treatment plans.
3. Initial assessment and history are crucial for establishing a baseline for future healthcare visits and monitoring the individual's progress.

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What is initial assessment and history?

Initial assessment and history is the process of gathering information about a patient's medical history, current symptoms, and any relevant background information to make an initial evaluation.

Who is required to file initial assessment and history?

Healthcare providers or medical professionals are required to file initial assessment and history for each patient they see.

How to fill out initial assessment and history?

Initial assessment and history can be filled out by documenting the patient's medical history, current symptoms, and any relevant information in a standardized form or electronic health record system.

What is the purpose of initial assessment and history?

The purpose of initial assessment and history is to gather comprehensive information about a patient's health status to help determine the best course of treatment and care.

What information must be reported on initial assessment and history?

The information reported on initial assessment and history may include past medical history, current medications, allergies, family history, social history, and current symptoms.