ADL General Collection Information: Difference between revisions
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Ttenbergen (talk | contribs) spun "Data Entry Instructions" into own section as elsewhere, separate from how to decide values |
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== Collection Instructions == | == Collection Instructions == | ||
*The ADL assessment should reflect the amount of assistance a patient requires to perform the six activities. It takes into consideration acute medical issues that resulted in admission to the hospital. | *The ADL assessment should reflect the amount of assistance a patient requires to perform the six activities. It takes into consideration acute medical issues that resulted in admission to the hospital. | ||
* using your best judgment based on age, diagnosis, pre hospital admission ADL, and 'where to get data' below, and select the option that best reflects their ADL status on admission to the ward | * using your best judgment based on age, diagnosis, pre hospital admission ADL, and 'where to get data' below, and select the option that best reflects their ADL status on admission to the ward | ||
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* Integrated progress notes | * Integrated progress notes | ||
* Risk assessment for falls form (if used) | * Risk assessment for falls form (if used) | ||
== Data Entry Instructions == | |||
*For every Medicine profile, enter the status into the ADL dropdown boxes in the [[Patient Viewer Tab ADL]] in [[CCMDB.accdb]]. | |||
=== Specific Activities collected === | === Specific Activities collected === | ||
Revision as of 12:35, 24 June 2025
The Activities of Daily Living (ADL) assesses a patient's capability to perform six daily self-care activities.
Collection Instructions
- The ADL assessment should reflect the amount of assistance a patient requires to perform the six activities. It takes into consideration acute medical issues that resulted in admission to the hospital.
- using your best judgment based on age, diagnosis, pre hospital admission ADL, and 'where to get data' below, and select the option that best reflects their ADL status on admission to the ward
- for ostomy care see ADL Toiletting and ADL Continence
- for use of mechanical aids see ADL Transfering
Timeframe
- The ADL assessment should be determined on admission to the ward (not the first Service tmp entry with the exception of EMIP)
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- The ADL assessment (done by allied health or nurses) we utilize is the patient's state of activity on admission to the ward (not at home prior to admission).
- If the patient is an EMIP use first Service tmp entry instead of the admission to the ward
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* using an ER based entry for EMIPs and a unit based entry for other patients would compare apples and oranges. It's a problematic idea, and the reason why we basically unified rules around collecting based on service start. If we want to create an exception for ADL (which will trickle into ALERT and possibly more) then we need to be very deliberate about this. Ttenbergen 09:54, 24 June 2025 (CDT)
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When possible, use an ADL assessment done within 24 hours after the admission to the ward
Directed Restrictions
Directed restrictions on a patient's activities should not be assessed as requiring assistance. For example, if a pt is on bed rest restrictions, it does not mean that they are unable physically to get out of bed. If the patient would be able to perform the activity if allowed then they are to be assessed accordingly. for example, if a patient comes in with a stroke, but can mobilize independently and go to the washroom, but is ordered to be on bedrest after a procedure, this would be coded as unassisted.
Where to get data
Data to evaluate ADL can be obtained from the following sources:
- OT/PT initial assessment
- Nursing activity flow sheets (if used)
- Nursing database or primary care patient record
- Integrated progress notes
- Risk assessment for falls form (if used)
Data Entry Instructions
- For every Medicine profile, enter the status into the ADL dropdown boxes in the Patient Viewer Tab ADL in CCMDB.accdb.
Specific Activities collected
See the following for specific coding instructions for the different activities.
Data Use
References/Background
The evaluation tool used for all Medicine patients is the Katz ADL.
- S Katz et al. Studies of illness in the aged: the index of ADL. American Medical Association, 1963.
- S Katz, SD Downs, HR Cash, RC Grotz. Index of daily living. The Gerontologist 1:20-301.