Effective Date: 
11/2018

Documents

Instructions

Updated: 11/2018

Purpose

Form 8584 is an assessment that contains all of the required elements of a comprehensive nursing assessment. The program provider may choose to create their own tool, provided it has all of the required elements. Form 8584 is used by registered nurses (RNs) in Home and Community-based Services (HCS) and Texas Home Living (TxHmL) to document a comprehensive physical and psychological assessment of an individual’s health history, including current health status and current health needs.  

The comprehensive nursing assessment must be completed for each individual when

 • nursing services are provided through the waiver; or
 • unlicensed personnel perform nursing tasks.

Form Retention

For individuals who utilize the agency option, HCS and TxHmL program providers must maintain a copy of the completed Form 8584 in the individual's record, in accordance with Texas Administrative Code, Title 40, Part 1, Chapter 49, §49.307.   

Procedure

The comprehensive nursing assessment must be:

 • completed by the selected RN at the time of enrollment to the program; and
 • reviewed at least annually face-to-face with the individual and when the health status of the individual changes. 

If the individual or legally authorized representative (LAR) refuses a nursing assessment, Form 1572, Nursing Tasks Screening Tool, must be completed by the selected program provider and individual or LAR. 

The RN should prioritize the need for a timely comprehensive nursing assessment for individuals based on acuity level.   

If an individual transfers to a new program provider, a nurse must perform nursing tasks directly if a nursing assessment cannot be completed immediately. The program provider must ensure that a comprehensive nursing assessment is completed as soon as possible before any unlicensed personnel can perform any delegated nursing tasks.  

The comprehensive nursing assessment must be conducted by an RN and is based on a physical assessment of the individual and a review of the individual’s medical records, including physician notes, lab results and all other pertinent clinical records. The nurse may document the source of any assessment information obtained from areas other than the nurse’s assessment. The nursing assessment should be written so that it can be understood by non-medical personnel. The nurse should use acceptable medical terminology and define terms if medical abbreviations are used. The RN must indicate if any information is self-reported by an individual or LAR which is not in the clinical record, e. g., “The individual stated he has a history of…”  

When conducting the comprehensive nursing assessment, the individual’s privacy must be respected and should be done in a private environment away from anyone who does not need to be included as part of the nursing assessment. If appropriate, an individual’s family/LAR or staff may be included for a portion or all of the nursing assessment to help gather information. The individual should always be consulted first and the nurse should ask who else the individual wants to participate. 

For any abnormal condition, describe the abnormal condition in the Comments section of the related item. Any additional findings or important information that is not listed on the comprehensive nursing assessment should be documented in the Comments section. 

Every field should be answered and the form should be completed in its entirety. If a field is not applicable, mark N/A. If the nursing assessment is filled out electronically, page numbers may change depending on how much additional information is entered in the Comments section. Attach any additional documentation or tools used to complete the assessment.  If Form 8584 is used, it must not be altered in way other than to add additional information.  

Detailed Instructions

Individual’s Name – Enter the individual’s full name as it appears on the individual plan of care (IPC). Note: The individual’s name should be at the top of each page of the form. The RN must sign or print their name at the bottom of each page of the form.

Date of Birth – Enter the individual’s date of birth. 

Today’s Date – Enter the date. Note: The date should be at the top of each page of the form.

Review of Health Care Team – Enter the name, title and health care organization for all health care professionals associated with the individual. Include the last date seen by the physician and any comments relevant to the individual’s treatment. Include any regularly scheduled appointments in the Comments field.

Natural Supports – Enter all natural supports that are active in the individual’s life. Include the relationship to the individual and contact information. Natural supports are any unpaid persons, including family members, volunteers, neighbors and friends who assist and sustain the individual. The Client Responsible Adult (CRA) is someone 18 or older, normally chosen by the individual, who is willing and able to participate in decisions about the overall management of the individual's health care and to fulfill any other responsibilities required for care of the individual. The term includes, but is not limited to, parent, foster parent, family member, significant other, LAR or legal guardian.

Health History, Axis I, Axis II, Axis III, Axis IV – Enter the individual’s psychiatric and medical diagnoses. Diagnoses can be found in the individual’s medical records as documented by a psychiatrist or a physician. If diagnoses information is obtained from a source other than a physician, clearly identify the source.

History of Major Medical/Surgical Occurrences – Enter a complete list of major medical history and surgical occurrences in the individual’s lifetime. Include the month and year the surgery took place, if possible.

Page 2

Review of Current Medications. Include OTCs, vitamins and herbs. – Document all current medications, including over the counter medications (OTCs), vitamins, herbal supplements, biologicals and alternative treatments. It is important to document the use of all substances, including topicals and other non-oral routes, in order to identify potential interactions with medications.

Allergies – Enter all types of allergies including, food, environmental, etc.

Medication – Enter all medications and update when medications change.

Dose – Enter the amount taken at a single time.

Freq. – Enter the frequency or number of times the medication is taken daily, weekly, etc.

Route – Enter the path by which the medication is administered into the body.

Purpose/Rationale – Enter the reason for the medication or expected outcome.

Side Effects/Labs – Enter major medication side effects specific to the individual. List labs recommended and/or ordered from a physician, if needed for medication.

Page 3

Current medical and psychiatric history – Briefly describe all current medical and psychiatric conditions and changes in health or behavioral status within the past year. Include any issues that required medical or psychiatric hospitalization.

What is of primary concern/greatest expressed needs . . .  – Briefly describe the primary concern/greatest expressed needs of the individual, LAR or individual’s responsible adult from their own perspective. This question should be asked directly to the individual, LAR or individual’s responsible adult. It is important to address the assessment in a person centered manner that focuses on relationship building with the individual. The individual should feel comfortable communicating health related issues with service providers and the nurse. Include medical, environmental, psychosocial and any needs specific to the person.  

Vital Signs – Enter the individual’s blood pressure (B/P), pulse rate and rhythm, respirations rate and rhythm, temperature in Fahrenheit, pain level, blood sugar, weight in pounds (lbs.) and height in feet and inches. If any vital sign was obtained from a source other than the current nursing assessment, include the source, e.g., self-reported, last machine reading/log book or recent clinical record. Vital signs are essential to a comprehensive nursing assessment and provide a baseline from which future health changes can be measured. Note: If the nurse does not feel that blood sugar is a necessary vital sign for the individual, the nurse may mark N/A in the space provided. 

Comments – Enter any information about the individual that is outside normal limits and the action taken as a result.

Page 4

Labs – Describe ordered labs, dates and abnormal values within the past year. Include standing orders for labs, frequency of labs and lab results. Indicate if any labs are ordered specific to a prescribed medication. 

Fall Risk Assessment – Check if a fall risk assessment has been completed. If yes, attach the assessment.  Indicate the reason for the fall risk, if known.

Comments – Describe what type of assistance the individual needs, gait belt, one-to-one assistance, mechanical lift (indicate type), etc.

Abnormal Involuntary Movement Scale (AIMS) Assessment – Review and attach an AIMS assessment to the assessment.  If deferred, explain why in the Comments field. Select Y for yes or N for no for the neurological symptoms listed.

Seizures – Document the typical frequency and duration if the individual has a history of seizures. Check Y for yes or N for no for the type of seizure the individual experiences. Indicate the date the last seizure occurred and the source of information. 

Page 5

Eye, Ear, Nose and Throat – Check the appropriate boxes for all findings that apply.

Comments – Enter the date of the individual’s last hearing test and eye exam, and indicate if the individual wears adaptive aids for vision or hearing. If the individual wears corrective vision, list the condition of the individual’s eye glasses. If hearing aids are used, document which type. Describe the condition of the individual’s gums, teeth, oral hygiene, and ability to speak and swallow food. Document if the individual has a history of eye disease, eye surgery or cataracts, ear surgery or drainage.  

Cardiovascular – Check Y for yes or N for no for each box. Document the individual’s normal blood pressure range and indicate if the individual is on blood pressure medication in the Comments field.

Comments – Enter any history of cardiovascular disease, e.g., heart attack, congestive heart failure or related symptoms.

Page 6

Respiratory – Check the box that best corresponds with the individual’s current breathing status. Check Y for yes or N for no for each box that follows.

Comments – Enter the size and type if the individual has a tracheostomy. If the individual is on a ventilator, include the ventilator settings as recommended by the doctor or respiratory therapist. Note: Respiratory function is a life or death issue and the nurse should identify needs as they apply to service delivery and follow up with nursing needs/delegation activities, as needed. Use a stethoscope to listen to all lung lobes. 

Gastrointestinal – Check the box for gastrostomy, jejunostomy or no tube. Enter the bowel sounds in all quadrants, the date and time of the last bowel movement, and the frequency and type of bowel habits. Check Y for yes or N for no for each box that follows.

Comments – Describe if the individual is on a bowel program. If the individual has a gastrostomy, G-Tube or J-Tube, document the size and type (e.g., 18FR, G-button), the formula used and the schedule. 

Page 7

Musculoskeletal – Check Y for yes or N for no for each box.

Comments – Describe the type of adaptive equipment and instructions for use. Include any recommendations by the physical therapist, if applicable.

Genitourinary – Check Y for yes or N for no for each box.

Comments – Describe if the individual is sexually active. If the individual is using birth control medications, refer to the medications list on Page 2.  

Integumentary – Check the appropriate box if the skin assessment is attached or deferred. Check the appropriate boxes describing the skin. Check Y for yes or N for no for each box that follows.

Comments – Describe any skin care issues, orders for wound care and wound care measurements, and any other important additional findings or important information that may not be on this form. If needed, use a diagram to represent the location of the wound. If the skin assessment is deferred, explain why.  

Page 8

Endocrine – Check Y for yes or N for no for each box. If the box for diabetes is Y, describe the management type and desired blood sugar range.

Comments – Describe the doctor orders for blood sugar checks and diet orders, if applicable. Explain any abnormal values, if applicable.  

Immunizations – Enter the date of the last immunization received in each box.

Comments – Describe the immunization history, if available.

Nutritional Assessment – Select the box for how the individual receives nutrition. If on a therapeutic diet, describe the type of diet and include the reason and date ordered. Fill in the appropriate answers and check Y for yes or N for no for each box that follows.

Comments – Explain any abnormal values and document how the weight was obtained and the type of clothing the individual wore.

Page 9

The information beginning on Page 9 is designed to get a snapshot of the individual’s lifestyle and how it relates to the individual’s health. It should be gathered by asking the individual open-ended questions in a person centered manner (for example, “Please tell me about …”). The questions should accommodate the individual’s style of interaction and preferences regarding time and setting. When conducting the nursing assessment, the nurse should explore the individual’s choices and preferences in reference to health care and also service delivery. The nurse should focus on building a relationship with the individual as it is important for the individual to feel comfortable communicating health related issues to their service providers and nurse. The nurse may receive information not related to the nursing assessment in respect to choices, preferences, or service delivery and should report any relevant information about the individual to the program provider and the service coordinator to make recommendations to revise the Person Directed Plan.

Sleep Patterns – Describe the average number of hours of sleep per night, if the individual has difficulty falling asleep, the number of times the individual wakes up at night, and the number and duration of naps during the day. Provide the individual’s sleep patterns and any additional information not listed on the nursing assessment. Include if lack of sleep disrupts the individual’s lifestyle.

Activity Level/Exercise – Describe the individual’s activity level, whether they get routine exercise, and what type of exercise they prefer. Document if the individual is on an exercise program recommended by a physician.

Substance Use/Abuse – Describe any use of caffeine, tobacco, alcohol, recreational drugs, and history of non-compliance with prescribed medications. Include the type, amount, frequency, duration of use, current and prior history of substance abuse, and any past history of hospitalizations for substance abuse.

Home Life Satisfaction/Desires – Describe if the individual feels safe in their current living environment and any environmental factors that contribute to their health and well-being. Ask the individual what makes them happy or unhappy in their home, if they enjoy their current living location/situation, and if they along with staff and roommates. Document the individual’s comments and any desires they have.

Work/School/Day Activity Satisfaction/Desires – Describe the activities the individual engages in on a regular and semi-regular basis. Document what the individual wants to be doing during the day in regards to work, school and recreational activities.  

Social Life Satisfaction/Desires – Describe the individual’s social interaction with peers and others in the community, including social activities that the individual enjoys. Document if the individual has friends that are not paid staff, if they have an opportunity to interact with friends outside of home and school, and if they have an opportunity to meet new people.

Spiritual Life Satisfaction/Desires – Document if the individual has religious preferences and if they attend or want to attend any religious functions. 

Coping Skills – Describe what the individual does when stressed and how they cope with positive and negative situations. Include if the individual has a behavioral plan or if it is recommended that the individual receive a behavioral assessment to determine need for behavioral supports.   

Page 10

Mental Status Appearance, Mood, Cognition and Emotions – Check the appropriate boxes based on observation of the individual. Add additional descriptions in the Comments field on Page 11. If findings are outside of the individual’s normal baseline, consult with others who have knowledge of the individual.   Describe the individual’s normal baseline, what has changed, when it changed and, if possible, why the change occurred.   

Cognitive Impairment, Memory and Emotions – Check Y for yes or N for no for each box. State any assessment tools used, if applicable, in the Comments field on Page 11. If unable to assess orientation or memory, note in the Comments.   

Page 11

Thoughts – Check Y for yes or N for no for each box. Provide any additional information in the Comments field.

Challenging Behaviors – Check Y for yes or N for no for each box. Fill in the frequency, severity and last exhibited fields based on review of the clinical records and interviews with others who have knowledge of the individual. If the individual has a formal behavioral plan, describe the plan and verify if it effectively addresses the individual’s challenging behaviors in the Comments field. Include if restraints are used as part of the behavioral support plan. If no plan is present, document if one is needed. If an individual is given a medication to control behavior, this would be considered a chemical restraint and a behavior plan is required.

Page 12

Communication – Check Y for yes or N for no for each box. Describe in detail any abnormal values in the Comments field.

Comments – Enter the names of persons/agencies used for interpretive services, if applicable. If the individual has a communication device, document if they can use it effectively. Describe if instructions are available for others to communicate with the individual and any behaviors the individual uses to communicate needs.

Page 13

Health care and Decision Making Capacity – Check the most appropriate box for the individual’s level of participation and accepted responsibility in their health care management.

Support Systems – Select the primary decision maker used to obtain information for the nursing assessment and check Y for yes or N for no for each box. Provide comments regarding the adequacy, reliability, availability and ability of the individual’s support system to communicate effectively. Document their availability to you and the individual and if they were they able to communicate effectively about the individual. If the primary decision maker status changes at any time, Section V, Implementation Assessment, must be updated.  If N was selected for any area, explain.

Stability and Predictability and Need to Reassess – Enter the health topics relevant to the individual and check Y or yes or N or no in regards to the ongoing nursing needs. Identify the frequency needed for RN assessment. Provide additional information in the Comments field on Page 14. Attach additional documentation if more than five health topics are included.  

Knowledge – Enter all health topics relevant to the individual and check Y or yes, N or no, or N/A for each in regards to the individual’s, CRA’s and HH/CC’s knowledge and demonstrates technique. Clearly identify any technique required for completing a health task in the Comments field on Page 14.

Page 14

Knowledge (continued) – Enter all health topics relevant to the individual and check Y or yes, N or no, or N/A for each in regards to the individual’s, CRA’s and HH/CC’s knowledge and demonstrates technique. Clearly identify any technique required for completing a health task in the Comments field.

Page 15

Participants in Comprehensive Assessment – Select Option A, B or C, whichever is most appropriate for the individual based on the comprehensive assessment, and discussion with, and involvement of, the individual, CRA, LAR or guardian. Check the appropriate box, print the name, sign and date the option.

 • Option A: If the individual does not have an LAR/guardian and has not requested assistance with their health care needs and can make decisions regarding their health care, the individual should complete Option A.

 • Option B: If the individual has requested assistance with their health care or cannot make decisions regarding their health care, the individual’s CRA should complete Option B. 

 • Option C: If the individual cannot make health care decisions and does not have an identified CRA able to participate in decisions, the Provider Advocate Committee will act as the CRA and check the box for Option C.  

Registered Nurse (RN)    – The RN who completed the nursing assessment prints their name, signs and enters the date.

Page 16

RN Delegation Worksheet – Check the box for attached or N/A. The RN must have Form 8585, RN Delegation Worksheet for 22 TAC Chapter 225, or comparable documentation attached to Page 16 if the RN is determining delegable nursing tasks for stable and predictable conditions.

Note: Page 16 cannot be left blank if an individual receives medication.

Safe Administration of Medications – Check the appropriate box in regards to the individual’s ability to self-administer their medication. The RN must select either the first box, Self-Administration of Medication, or the second box, Administration of Medication to an individual by a paid unlicensed person(s) to ensure that medications are received safely. If the second box is selected, then select at least one of the delegation options as listed below.

  • Self-Administration of Medication: The nurse has reviewed the five rights of medication administration for the individual listed on Page 16 and determined the individual’s ability to safely self-administer. The nurse can use a competency check list (interview, observation) and return demonstration                 routinely in accordance with best practice. If an individual health status changes, including changes in medication, the nurse must reassess competency of safe self-administration of medication.

  • Administration of medication to an individual by a paid unlicensed person(s) to ensure that medications are received safely: If the individual cannot show competency to complete all five rights of medication administration, the RN must determine which option best suits the individual’s               needs. The RN must choose one of the options listed in this section.  

   o CRA can safely direct as an HMA. No RN delegation is necessary. If the CRA has selected that they will participate in health care decisions and train unlicensed personnel in Option B on Page 15 (1st and 3rd check box), the nurse must select that the CRA can safely direct medication                       administration as an HMA. The RN must determine the CRA to be appropriate in order to select this option. The CRA must communicate with the RN regularly to provide updates on the individual’s medical status. The RN serves as a resource as needed.  
   o RN delegation necessary to ensure safe medication administration. This box is checked if the RN determines that delegation is required. The RN identifies routes of administration that may be delegated. Separate documentation to show delegation to unlicensed personnel must be                             completed and attached to Page 16. The RN must continue to monitor the individual at the frequency described on Page 17, Frequency of RN Monitoring.  
   o Routes that may be delegated. List all routes of medication that may be delegated, e.g., oral, topical, etc.  
   o The RN has determined that delegation is not required because the parent/LAR/foster care provider can assume responsibility and accountability for the individual’s health care. If this box is checked, the RN must complete and sign Form 8495, Exclusion of Host                                       Home/Companion Care (HH/CC) Provider from the Board of Nursing (BON) Definition of Unlicensed Person.  
    o The RN has determined that delegation is not required for oral, topical and metered dose inhalers. If this box is checked, the RN or an LVN under the direction of an RN has trained the unlicensed personnel regarding the proper administration of medication or determined that the                           unlicensed personnel is competent regarding proper administration of medication, including through a demonstration of proper technique. 
    o Must be administered by a licensed nurse. Medications that may not be delegated are: List all medications that must be administered by a nurse in accordance with the Texas Administrative Code Title 22 Part 11 Chapter §225.13(5).

Page 17

Nurse Supervision – List the persons who were consulted for this assessment and level of monitoring required for unlicensed personnel who perform nursing tasks. Include any additional information in the Notes field. Refer to the Board of Nursing rules for guidance. Describe any follow-up needed to monitor competency and identify if additional monitoring is required.

Page 18

Summary/Clinical Impression – Briefly document the individual’s strengths, based on the comprehensive assessment, as they relate to the individual’s health status. Include any consultations recommended and summarize the clinical impression of the individual.

Nursing Service Plan – List any specific health issues and nursing diagnoses requiring a nursing service plan.

Intervention/Strategies – Complete the fields in the table to summarize the nursing interventions and strategies for each concern listed. Include when the intervention will begin, when expected to be completed and the number of units needed for each strategy. For more than three concerns, expand or attach an additional table.

Total Nursing Units Needed – Determine the total number of nursing units needed by discipline and specialty, based on the comprehensive nursing assessment and nursing service plan. The total number of nursing service units may be greater than what is needed for the nursing service plan.

Desired Outcomes/Goals – Describe the desired outcomes/goals for each concern identified in the nursing service plan. Note: The nursing service plan is the basis for creating the implementation plan for nursing, including specific interventions, measurable realistic goals and outcomes for each concern identified. Each service on the IPC must have an implementation plan. The nursing service plan does not take the place of the implementation plan for nursing.

Page 19

Review of Comprehensive Nursing Assessment by RN – A comprehensive nursing assessment must be reviewed and updated at least annually, in accordance with Texas Administrative Code Title 40, Part 1, HCS and CFC Chapter 9 Subchapter D,  Certification Principles: Service Delivery §9.174 (a)(31) and with Texas Administrative Code Title 40, Part 1, TxHmL and CFC Chapter 9 Subchapter N, Description of TxHmL Program Services §9.555 (c).  Although Form 8584 may not need to be rewritten with each assessment, all elements of Form 8584 must be reviewed with the individual on an annual basis. Any changes in health status must be clearly documented.   

For each nursing assessment review, enter the date of review, select the appropriate purpose, describe the individual’s health status and any changes identified. Include current vital signs, weights and any other clinical values obtained during the review, e.g., blood glucose level. Document any actions taken by the RN and any changes needed in the nursing service plan. 

Signature – RN and Date – The RN signs and dates the assessment update.  
 

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