return to clinical report
RISK ASSESSMENT SCALE
|
DATE
|
I. Physical Condition
|
II. Mental Condition
|
III. Activity
|
SCORE
|
| |
- Good
- Fair
- Poor
- Very Bad
|
- Alert
- Apathetic
- Confused
- Stupor/Coma
|
- Ambulent
- Walk/Help
- Chairbound
- Bed
|
I.
II.
III.
IV.
V.
VI.
|
|
IV. Mobility
|
V. Incontinence
|
VI. Nutrition
|
- Full
- Slightly Limited
- Very Limited
- Immobile
|
- Not
- Occassional
- Often/urine
- Urine & Stool
|
- Excellent
- Fair
- Poor
- None
|
| |
|
TOTAL ---->
|
|
LOW RISK = 6–9 MODERATE RISK = 10–14 HIGH RISK = 15–24
|
Interventions
-
-
-
|