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CareKit Forms
Monthly Assessment Checklist
Patient Information
Patient Name
Last Name
Medical ID
Facility Name
Room Number
Date
Reasonable Care
Yes
No
Advance Directive
Yes
No
Other
Educate Directive
Yes
No
Emergency Contact
Yes
No
First Name
Last Name
Emergency Contact Phone Number
Emergency Contact Email
Emergency Relationship
Has the client met their financial responsibilities with the facility?
Referrals
If answered no, please elaborate
Hospitalized
Yes
No
If answered yes, did we receive an incident report?
Patient Condition
Yes
No
If answered yes, do we obtain additional information?
Safety Cross Check
Yes
No
Room Clean
Yes
No
Other
Housing List
Yes
No
Facility Aware
Yes
No
Notes
Mental Health Follow Up
Yes
No
Other
Substance Abuse Program
Yes
No
Other
If answered yes, please obtain additional information.
Dme Updates
Yes
No
No Current
Other
Please elaborate
Does the patient have any concerns with medications?
Rehab & Follow Ups
Under Hospice
Yes
No
If answered yes, what is the name of the Hospice company?
Has Rehab Hours
Yes
No
Who is the caregiver?
How many rehab hours have been used?
Rehab Renewal
Yes
No
Other
Rehab Notes Requested
Any additional information?
Are there any area's of concern that need to be followed up on?
Concerns Addressed
If answered no, has there been any follow up?
Facility Notified
Yes
No
Other
Signature
Date
Assessment Time
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