Assessment Materials

QoL.SRI.DQ (Domain Questionaire)

The QoL.SRI.DQ is an interview tool comprised of closed ended questions used to determine a resident’s quality of life in multiple domain areas. Each question elicits a yes/no response to be followed up with a “how often response” and if the response reflects a poor quality, an “importance rating”. The QoL.DQ contains 12 domain areas which have been segmented into four decentralized assessment packets as to better merge with the work flow within the nursing home.   Each domain consists of 4-7 closed ended questions that address:: Comfort (CMF), Security (SEC), Privacy (PRI), Food Enjoyment (ENJ), Meaningful Activities (MA), Religious Preferences (REP), Relationships (REL), Functional Competence (FC), Individuality (ID), Dignity (DIG), Autonomy (AUT), Spiritual Well-Being (SWB).

Jump to Departmental Assessment Packets

QoL.SRI.ID (In-depth)

The QoL.SRI.ID is an in-depth questionnaire that is populated from the responses given during the QoL.SRI.DQ. The QoL.SRI.ID consists of opened ended questions and probes aimed at obtaining detailed information about specific QoL items that may require person-centered care planning. Each departmental assessment designates how many items should be selected for in-depth probing.  An assessor is not limited to the probes provided in the QoL.SRI.ID but is recommended to use them as a starting point for the in-depth interview.  There is also the option for a ‘wild-card’ item to be selected at the assessor’s discretion.  The wild-card is any item the assessor wants to address that may not have triggered during the DQ.

QoL.CP (Care Plan)

The QoL.CP is a basic care plan form that can be reused and updated as a resident continues along the course of the QoL assessment and care planning cycle. This care plan can be printed out and filled in as necessary to be presented at care conferences and referred to as needed. The QoL.CP provided can also be used as a template for a customized care plan your facility may chose to create.

View and download the PDF file of a blank QoL.CP

Departmental Assessment Packets

• Nursing
• Social Services
• Activities
• Chaplain
• Dietary

Nursing

The nursing assessment packet includes the domains for Comfort (CMF), Security (SEC), Privacy (PRI) and Functional Competence (FC).  These domains were determined to be most associated with nursing tasks.  These are also the domains where nurses would have the most knowledge of feasible tasks and would be able to provide the best resident education during the assessment for any questions on the four domains listed.

View and download the PDF of the Nursing Assessment Packet

Social Services

The social services assessment packet includes the domains Relationships (REL), Dignity (DIG), Individuality (IND) and Autonomy (AUT).  These domains are the best fit for the specified knowledge of the social service staff.  For care planning purposes these domains will involve multiple staff members throughout the facility so the social service staff should be prepared to interact with activities staff and CNAs to implement appropriate care plans for residents that trigger items in these domains.

View and download the PDF of the Social Service Assessment Packet

Activities

There are two versions of the activities assessment packet.  The first includes Meaningful Activities (MA), Religious Practices (REP) and Spiritual Well-Being (SWB) domains.  This assessment packet is applicable to a facility that does not have an on-site chaplain or religious coordinator.  The second version of the activities assessment packet has only the Meaningful Activities (MA) section and should be employed when a chaplain or religious coordinator has been identified as the appropriate assessor to complete the additional sections relating to religious practices and spiritual well-being.  If your facility has a chaplain but that person will not be participating in the assessment process activities should use Version 1 of the packet.  In the latter scenario the chaplain and activities staff will still work closely together as activities staff is often involved in organizing religious activities outside of when the chaplain is available.

View and download the PDF of the Activities Assessment Packet Version 1 (MA, REP, SWB)

View and download the PDF of the Activities Assessment Packet Version 2 (MA only)

Chaplain

The chaplain assessment packet is comprised of the domains Religious Practices (REP) and Spiritual Well-Being (SWB).  If there is a full time chaplain or religious coordinator on staff this individual should conduct this assessment and coordinate with the activities or social service staff when necessary for care planning purposes.

View and download the PDF of the Chaplain Assessment Packet

Dietary

The dietary assessment contains the Food Enjoyment (ENJ) domain.  A staff member from the dietary department with knowledge of residents’ dietary restrictions should complete this assessment so that they can appropriately guide the interview towards feasible care plan tasks.  For example if a resident on a mechanical diet would like spaghetti and meatballs every weekend a different care plan goal will need to be identified until the dietary restriction is lifted.  Hence the assessor will have to know the dietary needs of the resident prior to the assessment.

View and download the PDF of the Dietary Assessment Packet