Thursday, June 16, 2016

Elopment Risk Form

[Adult Day Services Center/Program Name]
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: ________________