Example Of Heent Assessment
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Example Of Heent Assessment

Comprehensivemultidisciplinarypatientassessmentfrm
Comprehensive Multidisciplinary Patient Assessment / ANNA & NKF Version: 7/22/08 1American Nephrology Nurses’ Association Introduction to the CMPA The Department of Health and age (CfC) for End-Stage Renal Disease (ESRD) Facilities on Aprthe final publishing of the CfC l Kidney Foundation (NKF) and American Nephrology Nurses’ Association (ANNA) to estguidelines to assist facilities in complying with the requirement for a comprehensive, individual assessments by each

The latter of 30 calendar days or 13 outpatient hemodialysis sessions beginning with

3 months after the completi At least annually for stable patients

At least monthly for unstable patients, including but not limited to, patients with the following:

Extended or frequent hospitalizations;

Marked deterioration in health status;

Significant change in psychosocial needs; or

Concurrent poor nutritional status, unmanaged anemia, and inadequate dialysis.Initial and annual assessmassessments.

When a patient's unstable status triggers a new assessment, the reassessment will likely be more narrow in focus.

However, the reassessment needs to include some review patient’s dialysis prescription must be Hemodialysis Patients: At least monthly by calculating an equivalent

At least every 4 months by calculating delivered weekly Comprehensive Multidisciplinary Patient Assessment / ANNA & NKF Version: 7/22/08 2The CMPA must consist of the following minimum Evaluation of current health status and medical condition, including co-morbid

Evaluation of the appropriateness of the dialysis prescrip Laboratory profile, immunization hi Evaluation of factors associated with anemistores, and potential treatment plans for administration of erythropoiesis-stimulating agent(s)

Evaluation of factors associated with renal bone disease

Evaluation of nutritional

Evaluation of psychosocial needs by a social worker

Evaluation of dialysis accee, arteriovenous fistulas,

Evaluation of the patient’s abilities, intein the dialysis care process; the preferred modality (hemodialysis or peritoneal dialysis) and setting (for example, home dialysis), and the

Evaluation of suitability for a transplantation referral, based on criteria developed by the transplantation referral, the basis for nonreferral must be documented in the patient’s

Evaluation of family and other support systems

Evaluation of patient’s current physical activity level

Evaluation for referral to vocational and physical rehabilitation services The interdisciplinary team is responsible for the completion of the assessment.The team, as ing the patient for ESRD, a social worker and a dietitian
example of heent assessment
.

facility and treatment team will individually determine who is responsible for completing the remaining criteria based on thei expertise, and organizational d consult with each other in the process of completing the and to aid in the development of an effective plan of care.

For responses noted in shaded boxes “it is anticipated that the item will need to be addressed in the plan of care.

Comprehensive Multidisciplinary Patient Assessment / ANNA & NKF Version: 7/22/08 3a list of problems.

The care team will create or adjust the plan of care to address the problems identified by the

Be individualized

Specify the services necessary to address the patient’s needs identified in the

Include measurable and expected outcomes

Include estimated timetables to achieve outcomes

Contain outcomes consistent with current evidence-base professionally-accepted The example assessment questions have been designemeasurement of progress, the use of evidenced-based assessment tools, and the engagement of the patient in the assessment process.

This example is in no way intended as the absolute sibility to meet the ilities.It is expected facilities will modify the documentation systems.intended to provide examples of the types of questions that physicians, registered nurses, dietitians, and social workers he requirements for a CMPA.

The

the questions have not been confirmed.dynamic process.

This document reflects the

of its version date.Please confirm with NKF procedures provided by dialysis providers to their facilities.Please check with your dialysis implementing any information provided here.Comprehensive Multidisciplinary Patient Assessment / ANNA & NKF Version: 7/22/08 4Reason for Assessment Complete for each assessment R1.

State Reason for day
Annual (stable patients)

Monthly (unstable patients)

R1a.If monthly, choose reason for unstable status.Choose all that apply.

Hospitalization – frequent or extended stay

Marked deterioration in health status

Change in psychosocial needs

Poor nutritional status and unmanaged anemia and inadequate dialysis
Demographics ial assessment only

Last name:

Preferred first name:
Middle initial:
.

What is the patient’s date of birth?
.

What is the patient’s , transsexual, or other:

What is the patient’s gender > (2728 CodingWhat is their country/area of origin or ancestry?
.

What is the patient’s race? (2728 Coding)

White

Black or African American

American Indian/Alaska Native

What is the name of Enrolled/Principal Tribe?
Asian What is their county/area of origin or
What is the date of the patient’s first
.

What is the date the patient started chronic dialysis at the current facility?
What is the patient’s learning Multidisciplinary Patient Assessment / ANNA & NKF Version: 7/22/08 5Medical History ial assessment only heart disease:

Angina at rest
Angina on exertion
Angina on dialysis

Heart failure:

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