* = Required Information
Name of Patient/Client
*
Gender
*
Male
Female
Age
*
Goals of Care
Patient will be free from injury
Patient will receive assistance with ADLs/IADLs
Other
(Check appropriate interventions, write specifics as needed)
Nutrition
Type of Diet
Plan/Prepare Meals/Snacks
Serve Meals
Assist with Eating
Offer Fluids
Fluid Restriction
Thicken Fluids
Body Mechanics/Mobility
Transfer
Assist
Stand/Pivot
Sliding Board
Bed rest
Hoyer
Ambulation
Assist
Cane
Wheelchair
Walker
Crutches
ROM/HEP
Apply Orthopedic Device
Other
Personal Care/Assistance with ADLs
Bathing
Tub
Shower
Bed
Chair
Shower Bench
Hand Held Shower
Other
Hair
Comb/Brush
Shampoo
Condition
General
Dress
Shave
Skin Care/ Grooming
Oral Hygiene
Clean Dentures
Brush Teeth
Mouthwash
Oral Swabs
Toileting
Assist to Commode / Toilet
Assist with Bedpan / Urinal
Catheter Care
Empty Catheter / Draining Bag
Diapers / Depends
Other
Homemaking
Shop
Straighten
Clean bathroom after use
Clean Kitchen after Meal Preparation
Make Bed
Change Bed Linen
Personal Laundry
Medication Reminder Assistance
Other
Other/Record
Temp A/O
Intake/Output
Pulse
B/P
Respiration
Observe Universal Precautions
Call office immediately for any fall, loss of consciousness, injury, oral temp above
, pulse above
or below
Safety Instructions
Dates
Reviewed By
For Period
Infection Control Instructions
Prepared By
*
Date
*
Patient/Responsible Party Signature
*
Relationship to Client
*
Physician Name
*
Physician Signature
*
Date
*
Submit