Elderly Assessment

Many of the routine health checks for an Elderly Assessment are brought together on the Elderly Management Plan and Elderly Summary Form.

To record an Elderly Assessment:

  1. From Consultation Manager, select the patient required and start a consultation if required.

  2. Now, either:

    • From the Navigation Pane, right click on Elderly and select either Summary or Management Plan.

    • Select Summary - Routine Checks - Elderly.

    • Select Select Summary Form , double click on the Clinical Entities folder, double click on the folder of the routine check you are recording and then and then double click on the green file next to Elderly.

  3. From the Elderly Assessment Management Form, select the data type to record the relevant information.

    From the Elderly Assessment Summary Form, point at the entry type to add, right click and select Add.

    Training Tip - A green tick means there is already an entry at this prompt, a red cross indicates no entry yet.

The advantage of the Management Plan over the Summary Form is the ease with which you can see previous entries in a category, both display exactly the same - Add screens for the different data.

If you want to make entries outside of the Summary Form or Management Plan, you can simply add any of the following data from Read Term - Add using the correct clinical terms, many are listed as examples in Community Nurses’ READ Codes.

The Elderly Assessment Summary Form has four sections:

Remember - If you are recording data, select OK to save, if you are not recording data, select Next to move to the next screen without recording a default entry, or Skip to to move straight to a specific -Add screen.

  • Residence (Summary Form only) - The clinical term defaults to 13F.. Housing dependency scale, update from the available list if required. In Type of residence, select from the available list as appropriate.

  • Next of Kin - The clinical term does not have a default and is not required here if you do not want to select one, see Finding a Read Code if required. In Relationship to next of kin, select from the available list as appropriate.

  • Carers - Carers should be entered in Patient Details, see Patient Details for details.

  • Risk Factors - The clinical term does not have a default and is not required here if you do not want to select one, see Finding a Read Code if required. Tick Risk factors present if appropriate and enter any comments in Notes.

  • Agencies (Summary Form only) - The clinical term defaults to 13G..00 Domiciliary services, update from the available list if required. In Type of Agency, select from the available list as appropriate.

  • Allowances received - The clinical term does not have a default and is not required here if you do not want to select one, see Finding a Read Code if required. Enter any comments in Notes.

  • Optician Last Seen - The clinical term defaults to 9N2U.00 Seen by optician, update from the available list if required. Enter any comments in Notes.

  • Previous occupation - The clinical term does not have a default and is not required here if you do not want to select one, see Finding a Read Code if required. Enter any comments in Notes.

  • Exercise - The clinical term defaults to 138..00 Exercise grading, update from the available list if required. In Type of exercise, select from the available list and enter any comments in Notes

  • Diet - Record the patient's dietary status, see Diet for guidance if required.

  • Vision - The clinical term defaults to 668..00 Ophthalmological monitoring, update from the available list if required. In Vision and Visual Aid, select from the available list as appropriate.

  • Hearing - The clinical term defaults to 2BL..00 O/E - hearing tested-8th nerve, update from the available list if required. In Hearing, select from the available list as appropriate.

  • Mobility level - The clinical term defaults to 13C..00 Mobility - social functioning, update from the available list if required. In Mobility level, select from the available list as appropriate.

  • Mental cognitive - The clinical term defaults to 225..00 O/E -state of mind, update from the available list if required. In Mental cognitive, select from the available list as appropriate.

  • Mental emotional - The clinical term defaults to 225..00 O/E -state of mind, update from the available list if required. In Mental emotional state, defaults to Satisfactory, select from the available list as appropriate.

  • Sleep (Summary Form only)- The clinical term defaults to R005.00 [D]Sleep disturbances, update from the available list if required. In Sleep pattern, select from the available list as appropriate and enter a value in Average hours per night.

  • Physical health - The clinical term defaults to 69D1.00 Geriatric health exam, update from the available list if required. In Physical health, defaults to Satisfactory, select from the available list as appropriate.

  • Over the counter (OTC) drug use - The clinical term does not have a default and is not required here if you do not want to select one, see Finding a Read Code if required. In Self medication, tick to indicate self medication. Enter any comments in Notes.

  • Drug compliance (Summary Form only) - The clinical term defaults to 8B3E.00 Drug compliance good, update from the available list if required. In Treatment compliance, select from the available list as appropriate.

  • Hygiene - The clinical term defaults to 69D1.00 Geriatric health exam, update from the available list if required. In Hygiene at home and Personal hygiene, select from the available list as appropriate.

  • Continence:

    • Urinary - The clinical term defaults to 394..00 Bladder- assessment, update from the available list if required. Enter any comments in Notes.

    • Bowels - The clinical term defaults to 393..00 Bowels - assessment, update from the available list if required. Enter any comments in Notes.

  • Over 75 consultation - The clinical term defaults to 68Q..00 Geriatric screening, update from the available list if required. Enter any comments in Notes

  • Weight (Summary Form only) - Record the patient's weight, see Adding a Weight for guidance if required.

  • Height (Summary Form only) - Record the patient's weight, see Adding a Height for guidance if required.

  • BP (Summary Form only) - Record the patient's blood pressure reading, see Adding a Blood Pressure for guidance if required.

  • Pulse (Summary Form only) - The clinical term defaults to 242..00 O/E - pulse rate, update from the available list if required. In Pulse rate enter the pulse recorded, enter any comments in Notes on rhythm.

  • Visual acuity (Left eye and Right eye) (Summary Form only) - The clinical term defaults to 2B7..00 O/E - visual acurity L-eye, update from the available list if required. In Visual acuity and Visual Aid select from the available list as appropriate. Enter any comments in Notes.

  • Peripheral oedema (Summary Form only) - The clinical term defaults to R023400 [D]Peripheral oedema, update from the available list if required. In Peripheral oedema, Laterality and Site of oedema select from the available list as appropriate. Enter any comments in Notes.

  • Foot care (Summary Form only) - The clinical term defaults to 2g5..00 O/E - foot, update from the available list if required. Enter any comments in Notes.

  • Urinalysis - Glucose (Summary Form only) - The clinical term defaults to 466..00 Urine test for glucose update from the available list if required. Select a Result Qualifier as appropriate.

  • Urinalysis - Protein (Summary Form only) - The clinical term defaults to 467..00 Urine protein test update from the available list if required. Select a Result Qualifier as appropriate.

  • Advice given (Summary Form only) - The clinical term defaults to 679..11 Advice to patient - subject, update from the available list if required. In Type of advice given and Advice select from the available list. Enter any comments in Notes.

  • Referred to - The clinical term defaults to 8HZ..00 Further care referral NOS, update from the available list if required. In Type of referral select from the available list. Enter any comments in Notes.

Note - To print this topic select Print in the top right corner and follow the on-screen prompts.