MEDICAL DEVICE ASSESSMENT FORM

This form is used prior to admission and annually to evaluate the resident’s use of medical devices to include electric and manual wheelchairs, hoyer lifts/other lifting equipment, bed rails, and special mattresses.

Resident: Room#:

Medical Device(s):

1. Is the resident non-ambulatory? YES NO

2. Does the resident’s level of consciousness fluctuate? YES NO

3. Does the resident have alteration in safety awareness due to cognitive ¯? YES NO

4. Does the resident have a history of falls? YES NO

5. Has the resident displayed poor bed mobility or difficulty moving to a YES NO

sitting position on the side of the bed?

6. Does the resident have difficulty with balance or poor trunk control? YES NO

7.  Does the resident have postural hypotension? YES NO

8. Is the resident on any meds which may require safety precautions? YES NO

9. Is the resident currently using the device for positioning or support? YES NO

10. Has the resident expressed a desire to have the device used for safety YES NO

and/or comfort?

11. Is the resident visually challenged? YES NO

MEDICAL DEVICE: EVALUATION OF FUNCTION AND SAFETY

ð  Device works per manufacturer directions

ð  Device is in good working order/condition

ð  Resident is able to use device safely

ð  Staff has been trained/inserviced on proper and safe use of the device

ð  Device enhances the resident’s ability to maintain mobility and/or independence

ð  Resident’s physician has recommended the use of this medical device

ð  Other:

RECOMMENDATIONS: USE MEDICAL DEVICE EXPLORE OPTIONS TO MEDICAL DEVICE USE

The positive and negative aspects of medical device use have been discussed with the resident and/or family, and the resident and/or responsible parties are aware of the risks involved with the use of this medical device.

Staff Signature Date

Resident Signature Date

Responsible Party Signature Date