Enquiry Record Name * First Last Date Of Birth Referral Date Name of Referrer Role Or Job Title Assessment Date Primary Reason For Admission General Information about Circumstances, Diagnosis etc Status — Select — Pending Completed Admission Discharged Transfered Enquiry withdrawn Personal Details Client Name * Name Of Assessor Assessment Location Placing Authority Social Worker Social Worker Tel no Social Worker Email GP Name GP Tel no GP Email Total Number Of 1:1 Hours Allocated Times of Planned 1:1 Location Need Assessment Assessment 1 Assessment 2 Assessment 3 Assessment 4 Breathing Assessment 1 Breathing Description Level Of Need — Select — Low Needs No Needs Average Severe Moderate Describe The Actual Needs Of The Individual Nutrition- Food and Drink Nutrition Description Describe Actual Needs Of The individual Continence Continence Level Of Need — Select — Low Needs No Needs Average High Needs Moderate Describe Actual Needs Of The Individual Personal care Personal Care Need Level Of Need — Select — Low Needs No Needs Severe High Moderate Describe Actual Needs Of The Individual. Skin (Including Tissue Viability) Assessment 2 Skin Assessment Level Of Need — Select — Low Needs No Needs Severe High Moderate Describe Individual Actual Level Of Need Mobility: Not including Wandering Where mobility issues are indicated a Falls assessment and Moving and Handling Risk Assessment should have been carried out and the impact and likelihood of any risk factors considered. Mobility Level Of Need — Select — Low Needs No Needs Severe High Moderate Describe Individual's actual Need Communication This section relates to difficulties in expression and understanding, in particular with regards to communicating needs. Communication Needs Level Of Need — Select — Low Needs No Needs High Moderate Describe Individual's actual Need. Altered States Of Consciousness ASC can be caused by a range of conditions such as epilepsy ASC Needs ASC Need — Select — Low Needs No Needs High Moderate Describe Individuals Actual Need Emotional And Psychological Needs Assessment 3 Emotional Needs Level of Need — Select — Low Needs No Needs High Moderate Describe Individuals Actual Need Cognition Level Of Need — Select — Low Needs No Needs Severe High Moderate Describe Individuals Actual Need. Behaviour Behaviour Needs Level Of Risk — Select — Low Needs No Needs Severe High Moderate Describe Individuals Actual Need. Medication Medication Need Level Of Need — Select — Low Needs No Needs Severe High Moderate Describe Individuals Actual Need. Activities Of Daily Living Assessment 4 ADL Need Need Level — Select — No Low High Moderate Describe Individuals Actual Need Identified Risk Identified Risk (1) Level Of Risk (1) — Select — Low High Moderate Action Required To Mitigate Risk (1) Additional Documentation Select File(s)
