LAWTON IADL RESULT

Date: [Date]
Patient: [Name or ID, age]
Lives: [Alone, with a partner, with family, or in supported housing]
Reason: [Baseline, memory assessment, change reported, before discharge, or follow-up]

INFORMANT
Answered by: [Patient, informant, or both]
Informant: [Name, relationship, and how often they see the patient]
Accounts agree: [Yes, or the domains where they differ]
Interpreter: [Language, or none]

EIGHT DOMAINS
Telephone: [0 or 1, and what the person does now]
Shopping: [0 or 1, and detail]
Food preparation: [0 or 1, and detail]
Housekeeping: [0 or 1, and detail]
Laundry: [0 or 1, and detail]
Transportation: [0 or 1, and how the person gets around]
Medications: [0 or 1, and who sets up the doses]
Finances: [0 or 1, and who pays the bills and does the banking]
Total: [0 to 8]
Function level: [Low function, partial dependence, or high function]

CHANGE IN FUNCTION
Last score: [Date and total, or first score]
Domains lost or regained: [Which, and since when]
Likely cause: [Cognitive decline, physical limits, sensory loss, low mood, or a new illness]
Never done: [Tasks the person has never done, so a 0 is not read as new loss]

CARE NEEDS
Help now: [Who helps with which task, and how often]
Unmet needs and risks: [Missed doses, unpaid bills, scams, unsafe cooking, driving, isolation]

PLAN
Assessment: [Cognitive testing, medication review, labs, home safety or driving assessment]
Services: [Home care, meal delivery, pharmacy blister packs, occupational therapy, social work]
Repeat: [Date or interval]

Clinician: [Name, credentials]