[an error occurred while processing this directive]
[an error occurred while processing this directive]

Appendix 4: Admission & Recertification Evaluation

Karnofsky Scale

 

Date: Date: Date: Date: Date: Date:
Score: Score: Score: Score: Score: Score:

 

 

Activities of Daily Living (ADL) Scale

  4 Independent 3 Uses a device 2 Needs personal assistance 1 Completely dependent
Bathing        
Dressing        
Toileting        
Transfer        
Continence        
Feeding        

 

Date: Date: Date: Date: Date: Date:
Score: Score: Score: Score: Score: Score:

 

 

Descriptive Scale

  1 2 3 4 5
ANOREXIA No fluids Some fluids Some soft food Has appetite Normal
CACHEXIA Skin & bones Extreme Very thin Normal Heavy
MOBILITY Unable to turn over Sits up Bears weight Limited walking Normal
PAIN Incapacitating Severe Moderate Mild None
DYSPNEA Incapacitating Severe Moderate Mild None

Date: Date: Date: Date: Date: Date:
Score: Score: Score: Score: Score: Score:
[an error occurred while processing this directive]