KATZ ADL RESULT

Date: [Date]
Patient: [Name or ID, age]
Setting: [Home visit, clinic, hospital ward, rehabilitation unit, or care home]
Rated by: [Name, credentials]
Sheet used: [Official Katz Index sheet from the Hartford Institute for Geriatric Nursing, or a local adaptation]

RATING
Based on: [Watched the person do it, what the patient reports, a family member or carer, or nursing records; say which for each activity if mixed]
Informant: [Name and relationship, if anyone besides the patient]
Period rated: [Today, the past week, or the usual state before a named illness]

THE SIX ACTIVITIES
Bathing: [Independent or dependent; what help, who gives it, how often]
Dressing: [Independent or dependent; which garments or fastenings need help]
Toileting: [Independent or dependent; getting there, clothing, cleaning]
Transferring: [Independent or dependent; bed and chair, equipment used, hands-on help]
Continence: [Independent or dependent; bladder, bowel, pads, catheter, or ostomy]
Feeding: [Independent or dependent; hand to mouth, tube feeding if any]

SCORE AND CHANGE
Total: [0 to 6, one point per activity done independently]
Meaning: [Full function, dependent in one activity, moderate impairment, or severe functional impairment]
Baseline: [Earlier total, its date, and where it was rated]
Difference: [Points gained or lost, and which activities changed]
Likely cause: [Acute illness, surgery, fall, delirium, pain, a known condition progressing, or no change]

HELP NEEDED
Who helps now: [Spouse, family, paid carer, nursing staff, or no one]
Gaps and risks: [Activities with no reliable helper, near falls, skin risk, carer strain]
Equipment: [Shower seat, grab bars, raised toilet seat, commode, walker, or none]

PLAN
Actions: [Home care referral, therapy, equipment, carer support, placement discussion, or none]
Other assessments: [Lawton IADL, cognitive screen, fall risk, frailty level, or a full geriatric assessment]
Rescore: [Date, interval, or trigger such as discharge or a fall]

Clinician: [Name, credentials]