LTC-QoL Example

Long-Term Care Quality of Life scale

Surname: Smith
Given Name: John
DOB: 1/1/1970
Room No.: 111
Health Care Practitioner:
CR No.		 #123456

ASSESSMENT:
The LTC‐QoL assessment is repeated over two consecutive weeks to allow for variability of events. The person is asked to consider what has happened over the previous week when answering questions. For those living with dementia, the proxy assessor needs to be familiar with the person and have observed that person over the past week in order to make informed responses to assessment questions.

SCORING:
Each column is added up for weekly score (maximum of 45 points) which is then divided by 9 to give a score out of 5 for each week of the assessment period.. Add both weekly scores to get total score /10.

     
DURING THE PAST WEEK(S) the
person being assessed has: 		Date: 19/04/2024 Staff Assisting: J Doe Date: 26/04/2024 Staff Assisting: J Doe
NEVER OCCASIONALLY
(1 TO 2 TIMES)		 SOMETIMES
(3-4 TIMES)		 OFTEN
(5-6 TIMES)		 ALWAYS
(DAILY)		 NEVER OCCASIONALLY
(1 TO 2 TIMES)		 SOMETIMES
(3-4 TIMES)		 OFTEN
(5-6 TIMES)		 ALWAYS
(DAILY)
                     
1. Participated in social activities
2. Participated in self‐care activities
3. Participated in health enhancement programs / activities
4. Exercised personal choices
5. Supportive contact with family and/or friends
6. Expressed that they ‘feel well’
7. Related easily with others nearby
8. Expressed that they ‘feel secure’
9. Appeared or acted happy /confident
Scoring:
      x 1       x 2       x 3       x 4       x 5       x 1       x 2       x 3       x 4       x 5
=       =       =       =       =       =       =       =       =       =      
 
Week 1 Score:
      ÷ 9 =       (max 5)
Week 2 Score:
      ÷ 9 =       (max 5) (Add both scores
for total score /10)
 

Comments – relevant to assessment factors:

Expressed feelings of loneliness.

TOTAL SCORE:       (max 10)
 
Assessment completed by self or with assistance: Yes ☑ No ☐ OR by proxy assessor: (name)
Last updated 13/10/2019