Elopment Risk Form

[Adult Day Services Center/Program Name]

ELOPEMENT RISK ASSESSMENT

Client:   _____________________________________                                                    Date:     _________________

Check all that apply:

1.     Orientation:

 Alert                  Confused *    Disoriented *

 Oriented:       Time                  Place                 Person

2.     Behavior:

 Calm                  Combative    Agitated *

3.     Ambulation:

 Independent *             ( Walker   Cane)

 Wheel Chair                                     Self Propels in Wheel Chair *

4.     Exit Seeking Behaviors: *

 Attempts to leave Center alone and is not safe to do so

 Observed attempting to open doors

 Verbalizes, “I’m going home…”

 Observed attempting to leave Center

 Other __________________________________

5.     “At Risk” Status:

If participant scores on any starred (*) items in question 1, 2, or 3, AND any item in #4, they are to be considered at risk for elopement.

6.     Client is “At Risk” for Elopement

 Yes                      No

7.     If yes:

 Update Service Plan

 Designate Risk on Assignment Sheet

 Informed Family and Document

 Update Monitoring Plan

 Other ________________________

Social Worker / Nursing Signature: __________________________        Date: ________________