Section 01
Demographics & Contacts
Client identification, next of kin, GP, pharmacy, and care team details
Client Details
Home Support Hours
Next of Kin & Nominated Representative
GP & Clinical Team
Consultant Specialists
Specialty
Consultant Name
Hospital
Phone
Section 02
Medical History
Diagnoses, surgical history, allergies, vaccinations, and hospital admissions
Active Diagnoses & Chronic Conditions
Diagnosis / Condition
ICD-10 (optional)
Since (Year)
Managed By
Surgical & Procedure History
Procedure
Year
Hospital
Complications
Allergies & Adverse Reactions
Alert: All allergies must be documented and communicated to all care staff. Wear red allergy band if applicable.
Allergen
Type
Reaction
Severity
Mental Health History
Hospital Admissions (Last 2 Years)
Hospital
Date
Reason
Duration
Falls & Fracture History
Vaccination Status
Section 03
Functional Assessment
Barthel Index · Katz ADL · Lawton IADL · Mobility · Continence · Communication
Barthel Index of ADL
Score: —/100
Score 0–100. 0–20 = Total dependence; 21–60 = Severe dependence; 61–90 = Moderate; 91–99 = Slight; 100 = Independent. Lower score = higher care need.
Bowels0=incontinent, 5=occasional accident, 10=continent
Bladder0=incontinent/catheterised unable, 5=occasional accident, 10=continent
Grooming0=needs help, 5=independent
Toilet Use0=dependent, 5=needs some help, 10=independent
Feeding0=unable, 5=needs help, 10=independent
Transfer (bed to chair)0=unable, 5=major help, 10=minor help, 15=independent
Mobility (on level)0=immobile, 5=wheelchair independent, 10=walks with help, 15=independent
Dressing0=dependent, 5=needs help, 10=independent
Stairs0=unable, 5=needs help, 10=independent
Bathing0=dependent, 5=independent
Total: — / 100 Dependence: —
Katz Index of Independence in ADL
Score: —/6
6 = Full independence; 4 = Moderate dependence; 2 or less = Severe dependence
Bathing
Dressing
Toileting
Transferring
Continence
Feeding
Score: — / 6
Lawton IADL Scale
Score: —/8
8 = Fully independent for IADLs; 0 = Fully dependent. Scores drop when individual items show dependence.
Ability to use telephone
Shopping
Food preparation
Housekeeping
Laundry
Mode of transportation
Responsibility for own medications
Ability to handle finances
Score: — / 8
Mobility, Communication & Dexterity
Section 04
Cognitive Assessment
MMSE · MoCA · Dementia & Delirium Screening · Behavioural Symptoms
Mini Mental State Examination (MMSE)
Score: —/30
24–30 = Normal; 18–23 = Mild impairment; 12–17 = Moderate; <12 = Severe impairment
Orientation to TimeYear, Season, Month, Date, Day — max 5
Orientation to PlaceCountry, County, Town, Building, Floor — max 5
RegistrationName 3 objects, score 1 per object — max 3
Attention & CalculationSerial 7s or WORLD backwards — max 5
RecallRecall 3 objects — max 3
Language — NamingName 2 objects — max 2
Language — Repetition"No ifs, ands, or buts" — max 1
Language — 3-Stage CommandTake paper, fold in half, put on floor — max 3
Language — Reading"Close your eyes" — max 1
Language — WritingWrite a sentence — max 1
Visuospatial — Copy intersecting pentagons— max 1
Total: — / 30 Interpretation: —
Montreal Cognitive Assessment (MoCA)
Score: —/30
≥26 = Normal; 18–25 = Mild cognitive impairment; 10–17 = Moderate; <10 = Severe. Add 1 point if <12 years education.
Visuospatial / Executive (trail, cube, clock)Max 5
Naming (lion, rhino, camel)Max 3
Memory (5-word learning — recall not scored here)
Attention (digit span, serial 7s, vigilance)Max 6
Language (repeat sentences, fluency)Max 3
AbstractionMax 2
Delayed Recall (5 words)Max 5
Orientation (date, month, year, day, place, city)Max 6
Education adjustment (+1 if ≤12 yrs education)
Total: — / 30 Interpretation: —
Dementia, Delirium & Behavioural Screening
Section 05
Mental Health Assessment
GDS-15 · GAD-7 · Suicidal Ideation · Sleep · Social Isolation · Loneliness
Geriatric Depression Scale — Short Form (GDS-15)
Score: —/15
0–4 = Normal; 5–8 = Mild depression; 9–11 = Moderate; 12–15 = Severe. Score 1 for each YES (Q1,5,7,11,13) or NO (Q2,3,4,6,8,9,10,12,14,15).
1. Are you basically satisfied with your life?
2. Have you dropped many of your activities and interests?
3. Do you feel that your life is empty?
4. Do you often get bored?
5. Are you in good spirits most of the time?
6. Are you afraid that something bad is going to happen?
7. Do you feel happy most of the time?
8. Do you often feel helpless?
9. Do you prefer to stay at home rather than going out?
10. Do you feel you have more problems with memory than most?
11. Do you think it is wonderful to be alive now?
12. Do you feel pretty worthless the way you are now?
13. Do you feel full of energy?
14. Do you feel that your situation is hopeless?
15. Do you think that most people are better off than you?
Score: — / 15
Generalised Anxiety Disorder Scale (GAD-7)
Score: —/21
0–4 = Minimal; 5–9 = Mild; 10–14 = Moderate; 15–21 = Severe anxiety. "Over the last 2 weeks, how often have you been bothered by…"
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
Score: — / 21
Suicidal Ideation, Sleep & Social Wellbeing
Safeguarding: Any positive response to suicidal ideation requires immediate escalation per SolidRock Safeguarding Protocol and referral to GP/CAMHS/CMHT.
Section 06
Nutrition & Hydration
MUST Tool · BMI · Appetite · Swallowing · Special Diets
Anthropometric Measurements
Malnutrition Universal Screening Tool (MUST)
Score: —
Score 0 = Low risk; Score 1 = Medium risk (observe, monitor); Score 2+ = High risk (refer to dietitian, improve intake)
Step 1: BMI ScoreBMI >20 = 0; 18.5–20 = 1; <18.5 = 2
Step 2: Weight Loss Score(Unintentional, over 3–6 months)
Step 3: Acute Disease EffectLikely no nutritional intake >5 days = add 2
Total MUST Score: — Risk: —
Appetite, Hydration & Swallowing
Section 07
Skin Integrity Assessment
Waterlow Scale · Braden Scale · Existing Wounds · Pressure Ulcer Risk · SSKIN Bundle
Waterlow Pressure Ulcer Risk Scale
Score: —
Score 10+ = At risk; 15+ = High risk; 20+ = Very high risk. Initiate pressure relieving measures accordingly.
Build/Weight for HeightAverage=0, Above average=1, Obese=2, Below average=3
Skin Type / Visual Risk AreasHealthy=0, Tissue paper=1, Dry=1, Oedematous=1, Clammy=1, Discoloured=2, Broken/spots=3
Sex / AgeMale=1, Female=2, 14–49=1, 50–64=2, 65–74=3, 75–80=4, 80+=5
ContinenceComplete/catheterised=0, Occasional incontinence=1, Catheter incontinent=2, Double incontinence=3
MobilityFully mobile=0, Restless/fidgety=1, Apathetic=2, Restricted=3, Inert/traction=4, Chair-bound=5
AppetiteAverage=0, Poor=1, NGT/fluids only=2, Anorexic=3
Special Risk — Tissue MalnutritionTerminal cachexia=8, Cardiac failure=5, Peripheral vascular disease=5, Anaemia=2, Smoking=1
Special Risk — Neurological DeficitDiabetes/MS/CVA=4–6, Motor/sensory paraplegic=4–6
Special Risk — Major Surgery / TraumaOrthopaedic >2h=5, Spinal cord injury=6, On table >2h=5
Medication RiskCytotoxics=4, High-dose steroids=4, Anti-inflammatory=4
Waterlow Score: — Risk Level: —
Braden Scale for Predicting Pressure Sore Risk
Score: —/23
23 = No risk; 15–18 = Mild risk; 13–14 = Moderate; 10–12 = High risk; ≤9 = Very high risk
Sensory Perception1=Completely limited → 4=No impairment
Moisture1=Constantly moist → 4=Rarely moist
Activity1=Bedfast → 4=Walks frequently
Mobility1=Completely immobile → 4=No limitations
Nutrition1=Very poor → 4=Excellent
Friction & Shear1=Problem → 3=No apparent problem
Braden Score: — / 23 Risk: —
Existing Wounds & Skin Conditions
Site
Type
Grade / Stage
Current Treatment
Section 08
Falls & Mobility Assessment
STRATIFY / Cannard · Berg Balance Scale · TUG Test · Home Hazards
STRATIFY Falls Risk Assessment (Cannard)
Score: —/5
Score 2+ = At risk; Score 3+ = High risk. Each YES = 1 point.
1. Did the client come to care following a fall, or have they fallen in the past month?
2. Is the client agitated? (Confused, anxious, unpredictable)
3. Is the client visually impaired to the extent that daily function is affected?
4. Does the client need to go to the toilet frequently? (Incontinence / urgency)
5. Transfer / mobility score (0 or 1 = at risk)0=Unable, 1=Major help, 2=Minor help, 3=Independent
STRATIFY Score: — / 5 Risk: —
Berg Balance Scale
Score: —/56
41–56 = Low fall risk; 21–40 = Medium risk; 0–20 = High risk. <45 = Suggests impaired balance requiring intervention. Each item scored 0–4.
1. Sitting to standing
2. Standing unsupported
3. Sitting unsupported
4. Standing to sitting
5. Transfers (chair to chair)
6. Standing with eyes closed
7. Standing with feet together
8. Reaching forward with outstretched arm
9. Retrieving object from floor
10. Turning to look behind
11. Turning 360 degrees
12. Placing alternate foot on stool
13. Standing with one foot in front
14. Standing on one leg
Berg Score: — / 56 Risk: —
Timed Up and Go (TUG) Test
<12 seconds = Low fall risk; 12–20 sec = Moderate; >20 sec = High risk
Home Hazard Assessment
Section 09
Pain Assessment
Numeric Rating Scale (NRS) 0–10 · Abbey Pain Scale · Pain Management
Numeric Pain Rating Scale (NRS 0–10)
0 = No pain; 1–3 = Mild; 4–6 = Moderate; 7–9 = Severe; 10 = Worst imaginable. Use when client can self-report.
NRS Score: 0 / 10 Category: No pain
Abbey Pain Scale (Non-Verbal / Dementia)
Score: —/18
For clients unable to self-report. 0–2 = No pain; 3–7 = Mild; 8–13 = Moderate; 14+ = Severe. Score 0–3 per item.
Vocalisation0=Absent, 1=Occasional moan, 2=Constant moaning, 3=Loud constant cries
Facial Expression0=Smiling, 1=Sad, 2=Grimacing, 3=Marked grimace
Body Language0=Relaxed, 1=Tense, 2=Rigid, 3=Flexed/fists
Behavioural Change0=None, 1=Mild agitation, 2=Moderate agitation, 3=Severe agitation
Physiological Change0=None, 1=Mild change, 2=Moderate change, 3=Marked change (↑BP/HR)
Physical Changes0=None, 1=Slight guarding, 2=Protecting area, 3=Intense guarding/rigidity
Abbey Score: — / 18 Pain Level: —
Section 10
Medication Assessment
Full Medication Reconciliation · Polypharmacy · High-Risk Medications · Compliance
Medication Reconciliation
Verify against GP letter, pharmacy Mediscan, and existing medication chart. Document all prescriptions, OTC, supplements, and herbal remedies.
Drug Name (Generic)
Dose
Route
Frequency
Indication
Polypharmacy & High-Risk Medication Review
High-Risk / STOPP Medications Present?
Section 11
Risk & Safety Assessment
SSKIN Bundle · MDRO & Infection History · Missing Person · Manual Handling · Wandering
SSKIN Bundle — Pressure Ulcer Prevention
SSurface
SSkin Inspection
KKeep Moving
IIncontinence / Moisture
NNutrition & Hydration
Infection History & MDRO Status
Alert: MDRO status must be communicated to all care staff. Appropriate PPE and isolation precautions must be in place before first contact.
Missing Person Risk Assessment
Manual Handling Assessment
Wandering Risk Assessment
Section 12
Restrictive Practice Assessment
Sensor Mat · Bed Rails · Chair Alarm · Floor Mattress · Other Restrictive Devices
HIQA / Legal Requirement: All restrictive practices require: (1) documented risk assessment, (2) least-restrictive alternative confirmed, (3) written consent from client/representative, (4) MDT agreement, (5) time-limited review. Refer to HSE Restraint Policy 2011.
Restrictive Practice Devices Assessment
🛏 Bed Rails
📡 Sensor / Movement Mat
🪑 Chair Alarm
🛌 Floor Mattress
🔒 Other Restrictive Practices
Section 13
Behaviour & Consent
ABC Behaviour Assessment · PINCH ME Assessment · Consent to Care
ABC Challenging Behaviour Assessment
ABC Analysis: Antecedent (what happened before) → Behaviour (what was observed) → Consequence (what happened after). Document each episode to identify triggers and patterns.
Date/Time
Antecedent (A)
Behaviour (B)
Consequence (C)
PINCH ME Assessment — Causes of Sudden Behaviour Change
PINCH ME helps identify reversible causes of acute confusion or behaviour change. Assess each domain before escalating or attributing change to dementia.
P — PainIs the client experiencing undiagnosed or untreated pain?
I — InfectionSigns of UTI, LRTI, wound infection, skin infection?
N — Nutrition / HydrationPoor intake, dehydration contributing to behaviour?
C — ConstipationBowel not opened recently? Distension or discomfort?
H — Help (environment)Change in carer, environment, or routine causing distress?
M — MedicationNew medication, change in dose, interaction, or side-effect?
E — EmotionalAnxiety, depression, bereavement, fear, or unmet emotional need?
Section 14
Key-to-Me Profile & PEEP
Person-Centred Profile · Personal Emergency Evacuation Plan · Life History
Key-to-Me — Person-Centred Profile
This section captures what matters most to the client — their preferences, values, and life story. Completing this helps staff provide truly personalised, dignified care.
Personal Emergency Evacuation Plan (PEEP)
PEEP is mandatory for all clients with mobility or cognitive needs. This plan must be reviewed at each assessment and shared with all care staff.
🏠 Evacuation Capability
📍 Escape Routes
🔥 Specific Risk Factors
📞 Emergency Contacts for Evacuation
Section 15
Sign & Submit
Assessment Summary · Signatures · Care Plan Trigger
Assessment Score Summary
| Assessment Tool | Score | Interpretation | Risk Level |
|---|
Overall Clinical Summary & Care Plan Triggers
Declaration & Signatures
By signing, the assessing clinician confirms that this assessment was completed in accordance with SolidRock Home Care LTD Policies and HIQA Regulation 23. The client / representative signature confirms consent to care and receipt of the Admission Assessment Summary.