An assessment is the gathering information and knowledge about a resident so an effective care plan be formulated. Understanding the resident’s limitations and strengths. An assessment must be completed by or under the supervision of a qualified director or professional.
*Please check with your Care Planning Director for any potential updates in required documention.
Questions asked may include:
What are the resident’s life long interests?
What does the resident prefer?
Are adaptations needed?
NOTE: Some residents may be independently capable of pursuing their own activities without interventions from the facility. This information should be noted in the assessment and identified in the plan of care.
The Assessment should reflect activity…
- preferences
- needs
- adaptations
- activity plan
- recommendations
Tyes of Assessment
- Initial Recreation Assessments
- Short-Term: Completed by the 5th day of admission
- Long-Term: Completed by the 14th day of admission
- Annual Recreation Assessment
- Significant Change or Correction
- Whenever a “Comprehensive Assessment” is completed
Demographic Data
- Name
- Age
- Sex
- Language
- Occupation
- Place of birth
- Educational level
- Date of admission
Medical and Functional Status Data
- Medical diagnosis
- Psychiatric problems
- Social/emotional status
- Emotional status
- Cognitive status
- Communication
- Physical capabilities
- Nutrition
- Behavior
- Precautions such as Communication
- Physical capabilities
- Nutrition
- Behavior
- Precautions
Subjective Information
- Name preference
- Needs
- Schedule preferences
- Time awake/availability for activities
- Use of free time
- Lifestyle
- Potential, ability or appropriateness to participate in structured activities (group or 1:1)
- Family relationships
- Cultural or ethnic needs
- Religion or spirituality
- Hobbies or membership in organizations or groups
- Past, present and possible future interests
- Barriers to leisure pursuits
- Adaptations or modification of activities
- Response to interview
Resident Assessment Summary
- Response to interview
- Summary of leisure pursuits
- Response to programs
- Adjustment to facility
- Location of leisure participation
- Socialization patterns
- Cultural considerations
- Spirituality/religion
- Family/friend support
- Barriers to leisure pursuit
- Adapted equipment
- Modification of activities
- Notification of specialty groups
- Tour (if applicable)
- Calendar review
- Recommendations
- Referrals
- CAA and Care Plan considerations
Sample Resident Assessment Summary
Mrs. Jane Doe was admitted to Care Center on 4/25/2017. She has adjusted well to the facility and spends much of the day engaged in leisure pursuits. She was able to appropriately answer questions regarding her leisure interests and stated thatshe enjoys the recreational activities offered at the facility. Mrs. Doe enjoys playing Bingo and was informed of the weekly games. Large print Bingo cards are provided due to visual impairment. She also enjoys playing dominoes with family and AARP volunteers. Recreation provided a set of large dominoes. Mrs. Doe speaks English and Spanish and has strong ties toher Hispanic background. She enjoys Spanish food and music and will be invited to the weekly Spanish Club. She also findsmuch strength in her religion and will be invited to weekly Mass and Rosary in the Chapel. In addition, she will be offered Communion on Sundays. Other independent activities include watching T.V. (game shows) and reading the Reader’s Digest. Recreation provided large print Reader’s Digests and informed Mrs. Doe of additional reading materials in the Rec. Room. Since her admission, Mrs. Doe has participated in several group activities such as: Catholic Mass, Rosary, Bingo, Crafts and Discussion Groups. She will be invited to these activities in addition to: Horticulture, Music Programs, Cooking Club, Social/Special Events and Movie Night. She was also informed of the Residents’ Council and stated she would like to attend. Mrs. Doe triggers for most time in activities and is awake most of the morning. There is no indication of a need to slow down. However, she stated that she has a lot of pain in her right arm and feels this might interfere with her activity participation. In addition to prayer, she finds solace in bird watching and listening to Classical and Spanish music. Her family is very supportive and has provided a cassette player, TV, and a birdfeeder in her room. For relaxation and pain management,Recreation will provide Classical and Spanish music, encourage prayer, and promote bird watching. See care plan for specific goals and plans.
If you’re interested in a comprehensive assessment form, other forms of documentation, and documentation training tools, please click here.
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