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The 8584 form, developed by the Texas Department of Aging and Disability Services, serves as a vital tool for healthcare professionals conducting comprehensive nursing assessments. Designed to be filled out by registered nurses, it gathers essential information about an individual’s health status and medical history. This form encompasses various components, beginning with a review of the individual's healthcare team, including details about their primary care physician and specialists, as well as any medications they are currently taking, whether prescription or over-the-counter. It also prompts a thorough analysis of the individual’s health history, including any major medical or surgical occurrences and their current health status. Important assessments, such as vital signs and a fall risk evaluation, are included, allowing for a well-rounded picture of the patient's condition. The review of systems section addresses neurological, cardiovascular, and sensory health, ensuring that practitioners have a comprehensive view of the individual's overall well-being. Through structured prompts and sections, the 8584 form aims to capture real-time health information while considering the expressed needs of the individual, their legally authorized representative, or their responsible adult.

8584 Example

Texas Department of Aging

Form 8584

and Disability Services

June 2014

Comprehensive Nursing Assessment

To be performed by a Registered Nurse

Individual

Date of Birth

Today’s Date

I. Review

Review of Health Care Team

Health Care Practitioners

Date Last Seen

Comments

Primary Care

Psychiatrist

Neurologist

Dentist

Optometrist

Natural Supports

Relationship

Telephone No.

Client Responsible Adult (CRA)

Guardian

Health History

Axis I:

Axis II:

Axis III:

Axis IV:

History of Major Medical/Surgical Occurrences:

RN

Form 8584

Page 2 / 06-2014

Individual

 

Date

Review of Current Medications

Include OTCs, vitamins and herbs

Allergies:

Medication

Dose

Freq.

Route

Purpose/Rationale

Side Effects/Labs

RN

Form 8584

Page 3 / 06-2014

Individual

 

Date

 

 

 

II. Current Status

Current medical and psychiatric history

Briefly describe recent changes in health or behavioral status, hospitalizations, falls, seizure activity, restraints, etc., within the past year.

What is of primary concern/greatest expressed needs of the individual, legally authorized representative (LAR) or client’s responsible adult (CRA) from their own perspective?

Vital Signs

Blood pressure

Pulse

Respirations

 

Rate

Rhythm

Rate

Rhythm

 

 

 

 

 

 

 

Temperature

Pain level

 

Blood sugar

Weight

 

Height

 

 

 

 

 

 

 

Comments

RN

Form 8584

Page 4 / 06-2014

Individual

 

Date

 

 

 

Labs

Briefly review ordered labs, dates and abnormal values within the past year.

Fall Risk Assessment

Has a fall risk assessment been completed?

No

Yes (attached). Fall risk due to:

Neurological

Musculoskeletal

Unknown

Comments

III. Review of Systems

Neurological

Abnormal Involuntary Movement Scale (AIMS) Assessment:

Attached

 

Deferred

 

 

 

Y

N

 

Y

N

Y

N

 

 

 

Pupils equal and reactive to

 

 

 

 

Headaches

light and accommodation

 

 

Tremors

 

Dizziness

Tremors

 

 

Heat/cold reflex

 

Impaired balance/

 

Numbness/tingling/

 

 

 

 

 

coordination

 

Paresthesia

 

 

Extrapyramidal symptoms

 

Medication side effects

 

Paralysis

 

 

 

 

 

Y

N

 

Y

N

Y

N

Seizures

Petit Mal

 

 

Clonic (repetitive jerking)

 

 

 

 

 

 

 

Frequency

 

 

Absence

 

 

Tonic (muscle rigidity)

 

Duration

 

 

Myoclonic (sporadic jerking) ...

 

 

Atonic (loss of muscle tone)....

 

Comments

 

 

 

 

 

 

 

RN

Form 8584

Page 5 / 06-2014

Individual

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eye, Ear, Nose and Throat

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eyes/Vision

 

 

 

 

 

 

 

 

 

 

 

Clear

Red

Right impaired

Left impaired

Adaptive aid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ears/Hearing

 

 

 

 

 

 

 

 

 

 

 

Normal

Ringing

Right impaired

Left impaired

 

Adaptive aid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nose/Smell

 

 

 

 

 

 

 

 

 

 

 

Within normal limits Smell:

intact

not intact

Nose bleeds

Frequent sinus congestion

Frequent sinus infection

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Oral

 

 

 

 

 

 

 

 

 

 

 

Within normal limits

Difficulty chewing

Mouth pain

Halitosis

Dentures

Edentulous

Involuntary tongue movement

Dry mouth from medications

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Throat

 

 

 

 

 

 

 

 

 

 

 

Within normal limits

Sore throats

Difficulty speaking

 

Difficulty swallowing

Tonsil enlargement

History of choking

Thyroid enlargement

 

 

 

 

 

 

 

Swallow Study:

Yes

No

Date:

 

Results:

 

 

 

Comments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cardiovascular

Y N

Edema.................................

Chest pain ...........................

High/Low blood pressure.....

Normal range

Comments

Y N

Cool/Numb extremities...........

Activities of daily living (ADL)

limitations...............................

Y N

Capillary refill less than or

equal to two seconds...............

Compression stockings ...........

RN

Form 8584

Page 6 / 06-2014

Individual

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Respiratory

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Breathing:

Slow

Normal

Rapid

Shallow

 

Painful

 

 

 

 

 

 

 

Y

N

 

 

 

 

Y

N

 

Y

N

Short of breath

....................

 

 

Feeding tube

...........................

 

 

 

Tracheostomy

 

 

 

 

 

 

 

 

 

 

 

 

Continuous positive airway

 

Wheezing

 

 

Positioning orders

 

 

pressure (CPAP)

 

Fatigue

 

 

Aspiration history

 

 

Inhalation agent

 

Cough

 

 

Pneumonia history

 

 

Oxygen @

 

Productive

 

 

 

 

 

 

 

 

 

 

 

Comments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gastrointestinal

Gastrostomy

Bowel sounds

Jejunostomy

No tube

Last bowel movement

Bowel habits (frequency and description)

 

 

Y NY NY N

Continent.............................

Frequent nausea .................

Frequent vomiting ...............

Indigestion...........................

Heartburn ............................

Appetite loss........................

Comments

Reflux......................................

Straining pain..........................

Diarrhea..................................

Odd stools...............................

Hemorrhoids ...........................

Independent toileting...............

History of risk constipation .......

History of risk impaction ...........

Bowel program .........................

Medications influencing bowels (laxatives, anti-diarrheals, Iron, Calcium, Anticholinergics, etc.)

RN

Form 8584

Page 7 / 06-2014

Individual

Musculoskeletal

Pain.....................................

Weakness ...........................

Stiffness ..............................

Comments

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y

N

 

Y

N

 

 

Y

N

 

Prosthesis

 

 

Impaired range of motion

 

Deformity

 

 

Impaired gait

 

Contractures

 

 

Adaptive equipment

Genitourinary

Y N

Incontinent..........................

Stress.......................

Urge .........................

Bladder program ................

Frequent urination ..............

Cloudy/dark urine ...............

Bloody urine .......................

Comments

Y N

Flank pain ...............................

History of urinary tract

infections ................................

Noctouria ................................

Discharge ...............................

Itching .....................................

Hemodialysis ..........................

Peritoneal dialysis...................

Y N

Sexually active.....................

Prostate issues ....................

Menstrual cycle regular........

Date of last menstrual period:

Menopausal:

If yes, date of onset:

Integumentary

Skin Assessment:

Attached

 

Deferred

 

 

 

 

 

 

 

Skin:

Normal

Moist

Dry

Cyanotic

Warm

Pale

Jaundice

Cold

Dusky

Flushed

 

 

 

Y

N

 

 

Y

N

 

 

Y

N

Open wound

 

Rash

 

 

Blemished

............................

 

Bruising

..............................

 

Diaphoretic

 

 

Poor skin turgor

 

Breakdown related to

 

 

 

 

 

 

 

 

 

 

adaptive aids/prosthesis

 

Risk for breakdown

 

History of breakdown

 

Comments

RN

Form 8584

Page 8 / 06-2014

Individual

Endocrine

Y N

Thyroid dysfunction ............

Atypical antiphychotics or other medications affecting blood sugar.........................

Pre-Diabetic hypoglycemic/

hyperglycemic episodes .....

Comments

Date

 

 

Y

N

 

Diabetes

 

 

If yes, type

Management:

Diet

Oral medications

Insulin

Other injectable medication to manage diabetes Desired blood sugar range:

IV. Additional Health Status Information Immunizations: Date last received

DPT

TOPV

HIB

MMR

TD

TDS

Flu Shot

Comments

Nutritional Assessment

How receive nutrition:

Therapeutic diet

Food texture

Orally

Via gastrotomy tube if residual

Liquid consistency

Reason/date/ordered by:

Via jejunostomy tube Other

YN

Recent weight change ...............................................

Recent changes in appetite/medication.....................

Satisfied with current weight......................................

Food use as a coping mechanism.............................

Assistive devices with eating .....................................

Use of medications that can cause difficulty

swallowing (e.g., Abilify, other psychoactives)...........

Knowledge of 4 basic food groups.............................

Access to healthy/appropriate diet.............................

Dietary deficiencies ...................................................

Adequate fluid intake.................................................

Nutritional supplements .............................................

Interactions with medications and food......................

Comments

lbs. gain

Desired weight range

Number of meals/snacks per day

loss over

RN

Form 8584

Page 9 / 06-2014

Individual

 

Date

 

 

 

Sleep Patterns

Average number of hours per night; difficulty falling asleep; number of times awake at night; number of naps during a day

Activity Level/Exercise

Substance Use/Abuse

Caffeine, tobacco, alcohol, recreational drugs, history of non-compliance with prescribed medications

Home Life

Satisfaction/Desires

Work/School/Day Activity

Satisfaction/Desires

Social Life

Satisfaction/Desires

Spiritual Life

Satisfaction/Desires

Coping Skills

RN

Form 8584

Page 10 / 06-2014

Individual

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mental Status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appearance

 

 

 

 

 

 

 

 

 

 

 

 

 

Posture:

Normal

Rigid

Slouched

Other:

 

 

 

 

 

 

Grooming and Dress:

Appropriate

Inappropriate

 

Disheveled

Neat

 

 

 

Facial Expression:

Calm

Alert

Stressed

Perplexed

Tense

Dazed

 

Other:

Eye contact:

 

Eyes not open

Good contact

 

Avoids contact

Stares

 

 

 

Speech Quality:

Clear

Slow

Slurred

 

Loud

Rapid

Incoherent

Mute

Mood

 

 

 

 

 

 

 

 

 

 

 

 

 

Cooperative

Excited

Irritable

Other/Describe

Uncooperative

Agitated

Scared

Depressed

Anxious

Hostile

Euphoric

Suspicious

Angry

Cognition

Y N

Cognitive impairment

Mild.....................................

Moderate ............................

Severe ................................

Profound.............................

Y N

Oriented

Person....................................

Place ......................................

Time .......................................

Y N

Attention span

Easily distracted ......................

Memory

Remote...............................

Recent ................................

Immediate recall .................

Emotions

Y N

Euphoric .............................

Happy .................................

Apathetic ............................

Sadness .............................

Y N

Depressed..............................

Anxious ..................................

Irritable ...................................

Y N

Hostile feelings .......................

Emotional lability ....................

Inappropriate affect.................

RN

Form Characteristics

Fact Name Description
Purpose of Form The 8584 form is a Comprehensive Nursing Assessment used to evaluate an individual's health status.
Authority This form is governed by Texas Administrative Code, Title 40, Part 1, Chapter 19.
Completion Requirement A Registered Nurse must perform the assessment to ensure accuracy and compliance.
Key Components The assessment includes sections on health history, current medications, vital signs, and a review of systems.
Update Frequency The form should be updated annually or whenever there are significant changes in health status.

Guidelines on Utilizing 8584

Filling out the 8584 form may seem daunting, but with a clear approach, you can complete it efficiently. This form requires detailed information about the individual’s health care needs and history. The information gathered will help create a comprehensive assessment to provide the best care possible.

  1. Gather Information: Collect all necessary personal and health-related documents. This includes medical history, medications, and any recent health reports.
  2. Complete Individual Information: At the top of the form, write the individual's name and date of birth. Don't forget to enter today’s date.
  3. Review Health Care Team: List all health care practitioners involved in the individual’s care. Note the last visit date and any comments. Be thorough.
  4. Identify Natural Supports: Provide information about any family members or friends who support the individual. Share their relationship to the individual and contact details.
  5. Record Health History: Fill out the sections related to health history, including axes I through IV. Include major medical or surgical occurrences.
  6. List Current Medications: Document all current medications, including over-the-counter drugs and supplements. Include doses, frequency, route, purpose, and any side effects.
  7. Detail Current Status: Write a brief narrative about the individual's current medical and psychiatric status. Address any changes in health, recent issues, or expressed needs.
  8. Vital Signs: Record the vital signs, including blood pressure, pulse, respiration, temperature, pain level, blood sugar, weight, and height.
  9. Summarize Lab Results: Create a brief overview of any labs ordered in the past year, noting dates and any abnormal values.
  10. Complete Fall Risk Assessment: Indicate if a fall risk assessment has been completed, and note contributing factors such as neurological or musculoskeletal issues.
  11. Review Systems: Go through the system review sections and mark any relevant findings for neurological, cardiovascular, and sensory evaluations.
  12. Provide Comments: Throughout the form, use the comments sections to add any other relevant details that could be important for care considerations.

Once you've filled out the form, review all information for accuracy and completeness. Ensuring each field is addressed will help in the evaluation process. With everything in order, you can submit the form and move forward with the assessment process.

What You Should Know About This Form

What is Form 8584?

Form 8584 is a Comprehensive Nursing Assessment used by the Texas Department of Aging and Disability Services. It is designed to assess the health and functional status of individuals in need of care. This assessment is performed by a registered nurse and covers a wide range of health-related information.

Who completes Form 8584?

A registered nurse completes Form 8584. This professional is tasked with conducting a thorough review of the individual's health history, current medications, and other relevant factors impacting the person's care and well-being.

What information is required on Form 8584?

Form 8584 requires various types of information, including the individual’s medical history, recent changes in health status, allergies, current medications, and vital signs. It also assesses specific systems, such as neurological, cardiovascular, and sensory functions. Additionally, comments from the individual or their responsible adult may be included to highlight specific concerns.

Is a fall risk assessment included in Form 8584?

Yes, Form 8584 includes a fall risk assessment. The registered nurse will determine whether an assessment has been completed and will note any fall risks identified, such as neurological or musculoskeletal factors. This is crucial for ensuring the safety of the individual.

What happens if a medication is identified with side effects?

If any current medications are noted to have potential side effects, these are documented on Form 8584. It is important for the nurse to communicate these findings to relevant health care providers to address any concerns and adjust medications as necessary.

Can supplementary information be attached to Form 8584?

Yes, supplementary information such as lab results or additional assessments can be attached to Form 8584. This provides a more comprehensive view of the individual’s health status and is encouraged for ensuring thorough evaluations.

How often should Form 8584 be completed?

Form 8584 should be completed as needed, particularly when there are significant changes in the individual’s health condition or upon admission into a care facility. Regular updates may be required to ensure accurate and current health assessments.

What role does the Client Responsible Adult (CRA) play in the assessment?

The Client Responsible Adult (CRA) or legally authorized representative plays a crucial role in the assessment process. They provide valuable insights regarding the individual’s specific needs and concerns, ensuring that their perspective is incorporated into the overall evaluation.

Where can I access Form 8584?

Form 8584 can typically be accessed through the Texas Department of Aging and Disability Services website or obtained from health care providers involved in the care process. Ensure that you are using the most recent version to comply with current regulations and standards.

Common mistakes

Filling out Form 8584 correctly is crucial for a comprehensive nursing assessment. However, many people make common mistakes that can lead to incomplete or inaccurate information. One frequent error is not providing enough detail in the health history section. This includes failing to document important past medical or surgical occurrences. Such omissions can prevent health care providers from gaining a full understanding of a patient’s background and needs.

Another mistake often made is neglecting to list all current medications, including over-the-counter drugs, vitamins, and herbal supplements. Missing this information can lead to dangerous drug interactions or misunderstandings about a patient’s treatment plan. It is essential to review and update medication lists thoroughly before submitting the form.

People also sometimes fail to report changes in the individual’s current medical or psychiatric status. The section addressing recent changes, hospitalizations, or any concerning behaviors should be completed with care. This information is vital for health care professionals to provide appropriate support and adjustments to care based on the individual's most recent conditions.

Completing the vital signs section incorrectly is another common issue. It’s important to ensure accuracy in recording blood pressure, pulse, respirations, and temperature. Any discrepancies can mislead caregivers about the patient’s current condition. Moreover, neglecting to comment on pain levels, blood sugar, weight, and height can leave significant gaps in information.

The fall risk assessment section is often overlooked or filled out inadequately. It is necessary to either attach a completed fall risk assessment or provide thorough details explaining the patient’s risks. This assessment can result in critical interventions that might prevent falls and enhance safety.

Lastly, failing to provide comments or additional notes in various sections can be detrimental. Always include relevant observations, especially in sections reviewing systems and current medication side effects. These notes can guide healthcare teams in making informed decisions about care. Taking the time to ensure each part of Form 8584 is complete and accurate benefits both the individual and their care team.

Documents used along the form

The Texas Department of Aging Form 8584 is primarily used for comprehensive nursing assessments. While this form serves a specific purpose, several other documents may be required to support its findings or to provide additional context. Here is a list of related forms and documents that are often used alongside Form 8584.

  • Consent for Treatment Form: This document grants permission for healthcare providers to administer treatment or perform procedures on a patient. It ensures that clients or their guardians understand the risks and benefits of treatments offered.
  • Medical History Form: This form captures a patient’s past medical and surgical history. It provides a comprehensive overview of previous conditions, treatments, and outcomes that can influence current care.
  • Medications Administration Record (MAR): The MAR is used to document all medications administered to a patient. This record includes details such as dose, frequency, and administration route, ensuring medication management is tracked effectively.
  • Fall Risk Assessment Form: This document evaluates a patient’s risk of falling based on various factors including medical history and functional abilities. It is often used in conjunction with the Form 8584 to assess safety in care settings.
  • Nursing Care Plan: A nursing care plan outlines specific care strategies based on assessment findings. It details nursing diagnoses, goals, and interventions tailored to the individual’s needs as identified in the 8584 form.
  • Incident Report Form: This form is completed following any incident that affects a patient’s health or safety. It documents details such as nature of the incident and responses, and is vital for quality control and improvement.
  • Client Rights and Responsibilities Form: This document outlines the rights of patients and their responsibilities while receiving care. It helps ensure that clients understand their entitlements and obligations in a healthcare setting.
  • Health Insurance Portability and Accountability Act (HIPAA) Authorization Form: This form is necessary for sharing a patient’s protected health information (PHI) with others, typically required for treatment or billing purposes.
  • Advanced Directive Form: This document provides guidance on a patient's preferences for medical treatment in case they become unable to communicate their wishes. It can include living wills and powers of attorney.
  • Discharge Summary Form: This form summarizes a patient’s health status upon discharge. It includes treatment received, follow-up plans, and any ongoing needs, ensuring continuity of care post-discharge.

These documents are essential in providing a comprehensive view of a patient’s health, ensuring that care is tailored to individual needs while also adhering to legal and procedural standards. Each form plays a specific role in the broader context of healthcare documentation.

Similar forms

  • Form 485: This is a similar document used for home health care services. It encompasses health assessments and care plans for individuals, much like the comprehensive evaluations in Form 8584.
  • Form 5500: This form is utilized for employee benefit plans. It helps in reporting health and welfare benefits, establishing compliance with regulations, akin to the assessment of medical needs in Form 8584.
  • Form CMS-1500: Primarily used for insurance claims, this form collects similar health information and services rendered by healthcare providers, aligning with the medical history collection in Form 8584.
  • Form 1040: While typically associated with taxes, certain sections require disclosures about health expenses. This reflects the financial aspect of healthcare that impacts the assessments in Form 8584.
  • Form I-485: This application for a green card collects personal health and background information, similarly examining individual circumstances as seen in Form 8584.
  • Form 2781: Used for Medicaid eligibility determination, it gathers health and financial information, paralleling the detailed health reviews in Form 8584.
  • Form 1493: Similar to Form 8584, this document is used for disability claims and includes assessments of medical conditions and support needs.
  • Form MDS (Minimum Data Set): This assessment tool is used in nursing homes to evaluate residents' medical, physical, and mental conditions, sharing a focus on comprehensive evaluations like Form 8584.

Dos and Don'ts

When filling out the 8584 form, it's essential to follow some basic guidelines to ensure accuracy and completeness. Here are four things you should and shouldn't do.

  • Do provide complete and accurate personal information, including the date of birth and today's date.
  • Don't leave any sections blank unless instructed. Fill in all relevant details to avoid delays.
  • Do list all current medications, including over-the-counter drugs, vitamins, and herbal supplements.
  • Don't assume the reviewer knows the individual's medical or psychiatric history. Provide thorough explanations for any changes or concerns.

Misconceptions

Misconceptions about the Texas Form 8584 can often lead to confusion and frustration regarding its purpose and use. Here's a list of common myths and explanations to clarify them:

  • Form 8584 is only for elderly patients. This form is designed for individuals of various ages who require a comprehensive nursing assessment, not solely for older adults.
  • You only need to fill out Form 8584 if there are major health issues. Even if the patient appears healthy, this form helps establish a baseline for future assessments and identifies potential risks.
  • All healthcare providers are required to use Form 8584. While it is a standard form in many facilities, not every provider may use it. Some may employ different assessment tools based on their protocols.
  • The assessment must be completed by a doctor. Form 8584 specifically states that it should be performed by a registered nurse, ensuring nurses play a key role in patient assessments.
  • Once submitted, the form cannot be updated. Updates and revisions are allowed; it's important to keep the information current as the patient’s health status changes.
  • Filling out the form is optional. For many healthcare facilities, a comprehensive nursing assessment and the subsequent documentation are mandatory processes for patient care.
  • Form 8584 is complicated and time-consuming. While thorough, the form is structured to facilitate clear communication among care teams, ultimately benefiting patient care.
  • The form only gathers medical information. It also includes assessments of social factors and patient concerns, providing a holistic view of the individual’s needs.

Understanding these misconceptions helps clarify the importance of the Form 8584 in delivering quality healthcare. It serves as a vital tool for capturing a complete picture of an individual's health status and supporting their healthcare journey.

Key takeaways

Filling out and utilizing the 8584 form properly is essential for ensuring comprehensive nursing assessments. Here are some key takeaways to consider:

  • Preparation is crucial. Gather all necessary medical history, including information about medications, allergies, and previous medical encounters before starting the form.
  • Details matter. Provide thorough descriptions of the individual's health status, changes in behavior, and any recent hospitalizations or falls to paint a complete picture for healthcare providers.
  • Team collaboration is important. Consultation with the healthcare team, including primary care and specialists, is encouraged to ensure that all viewpoints are represented and any concerns are addressed.
  • Ongoing monitoring is necessary. Regularly review and update the individual’s information, including vital signs and lab results, to reflect any changes in their condition.
  • Fall risk assessments should be prioritized. Completing a fall risk assessment is vital, as it helps identify potential hazards and informs strategies to prevent falls in high-risk individuals.