How to Document ADL

ADLs are essentially what you do with your time all day and how independently you do it. As a formal medical and nursing term, "Activities of Daily Living" ranks an individual's ability to provide safe self-care along a continuum ranging from independent to utterly dependent. Six to 20 areas of life skills, depending upon the scale used, are examined. Some scales are designed for use for home evaluations while others concentrate on nursing home situations. Evaluators do not simply accept an individual's verbal and subjective reports of self care, but also utilize assessment skills to ensure that the patient meets minimum and safe standards.

Things You'll Need

• ADL checklist or measuring scale

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Instructions

• 1

  Assess the individual's ability to bathe. Does the patient require assistance in bathing or in getting in or out of a tub or shower? Keep in mind that many elderly patients stop using a tub or shower for fear of slipping and falling and are dependent upon "sink baths." Would installation of grab bars or use of a shower chair help the patient return to showers or baths? Document what form of bathing she performs, the frequency it is conducted and the apparent effectiveness of the effort.

• 2

  Assess the patient's toileting. I he continent? Does she use disposable pads or diapers for incontinence occasionally or routinely? Is he able to reach the bathroom in time? Is she capable of sitting on a commode and then stand up from the sitting position? Can he clean himself appropriately after toileting? Document the patient's toileting routine, approximate number of bathroom visits per day, use of incontinent aids and post-toileting hygiene effectiveness.

• 3

  Assess the individuals dressing abilities. Do he dress himself independently and appropriately and able to manage buttons, zippers and snaps? Can she pull a shirt on over her head and maneuver her arms into the sleeves? Can he put on his shoes on independently and tie, buckle or use velcro closures? Document the dressing routine, any adaptions (such as slip-on shoes to avoid tying laces), degree of independence and appropriateness of clothing.

• 4

  Assess the individual's grooming. Is he able to brush his teeth or perform appropriate oral care in the case of removable dentures? Can she comb and style her hair? Is he able to shave? Can she apply cosmetics? Does she wear jewelry or watches and if so, is she able to put these items on independently? Are he able to trim his nails as needed? Document the individual's grooming routine, independence and apparent ability.

• 5

  Assess the individual's ability to self-transfer and overall mobility. Does he require assistance in rising from bed after sleep? Can she stand from a seated position without assistance? Have he adopted any modifications or pieces of durable medical equipment (DME) such as higher-seated chairs, walkers or grab bars? Is his balance impaired? What distance is she able to walk? Can he climb stairs? Document the individual's transfer and basic mobility in transfers as well as any adaptations.

• 6

  Assess the individual's ability to feed themselves. Does he prepare his own meals and if yes, how so? Does she plan her own meals? Does he use utensils to feed themselves? Can she swallow? Is he capable of cleaning used pots, dishes and cutlery? Document the individual's ability to prepare, eat and clean up after meals, the number of times per day this is accomplished and the individual's current weight.

• 7

  Assess instrumental ADLs. Instrumental ADLs refer to those tasks required to maintain a household, such as cleaning, preparing meals, doing laundry, taking medications, using the telephone, paying bills, shopping and arranging transportation. If appropriate, document the patient's ability to perform instrumental ADLs, what degree of assistance is used and what additional assistance might be required.