Purpose
The RN Assessment ensures that clients receive the right level of care, supports safe care planning, and helps determine whether services can be delivered by a PSW, RPN, RN, or a coordinated care plan. The assessment supports client safety, practitioner readiness, and continuity of care.
When an RN Assessment Is Required
An RN assessment may be required when:
- The client does not have a documented care assessment within the past 6 months
- The client’s needs are complex, changing, or unclear
- Nursing care or clinical oversight is requested
- There are identified risks related to mobility, cognition, medication, or health status
- Caredara™ determines an assessment is needed to ensure safe care delivery
Assessment Format
RN assessments may be conducted:
- In-person (preferred for higher-risk or complex cases)
- Virtually (when appropriate and clinically safe)
The format is determined based on:
- Type of service requested
- Client risk level
- Clinical judgment of the RN
Core Assessment Components
1. Client Profile
- Client demographics and living situation
- Primary reason for care request
- Primary caregiver(s), if applicable
- Cultural, language, or communication considerations
2. Health and Medical Overview
- Relevant medical conditions and diagnoses
- Recent hospitalizations, surgeries, or changes in health
- Current symptoms or health concerns
- Allergies and precautions
3. Functional Assessment
- Mobility level and transfer needs
- Ability to perform activities of daily living (ADLs)
- Use of mobility aids or equipment
- Fall risk indicators
4. Cognitive and Psychosocial Status
- Orientation, memory, and cognitive functioning
- Behavioural or emotional considerations
- Social supports and isolation risks
- Decision-making capacity (if applicable)
5. Medication Review
- Current medications (as reported by client/family)
- Medication management needs (e.g., reminders, administration support)
- Potential risks or concerns related to medications
6. Safety and Environment
- Home safety considerations
- Infection control or hygiene concerns
- Environmental risks (stairs, clutter, accessibility barriers)
- Emergency contacts and escalation plan
Care Recommendations
Following the assessment, the RN will:
- Recommend appropriate practitioner type(s) (PSW, RPN, RN)
- Identify care tasks within scope of practice
- Outline any limitations, precautions, or monitoring needs
- Determine if care coordination or follow-up assessment is required
- Recommend reassessment timelines if conditions change
Documentation and Communication
- Assessment findings are documented in the Caredara™ platform
- Key care instructions are shared with assigned practitioners
- Clients and/or families are informed of recommendations and next steps
- Any identified risks are flagged for operational follow-up
Limitations
- RN assessments do not replace ongoing primary care or physician services
- Assessments are based on information available at the time of revie
- Changes in client condition may require reassessment
Client Consent
- Client or substitute decision-maker consent is required prior to assessment
- Clients may decline recommended services but will be informed of potential risks
Review and Updates
- Assessments may be updated if care needs change
- Caredara™ reserves the right to request reassessment to ensure safe care delivery
Guiding Principle
Caredara™ RN Assessments are designed to support safe, appropriate, and flexible care, respecting client autonomy while ensuring practitioners are set up for success.