Care Plan

(Fill in, Circle and/or “X”)

Name: ___________________________________________ Date of Birth: ____/____/____

Long-Term Care (12-24months)

Short-Term Care (6-12months)

Service(s): __________________________________________________________________

Hands on assistance

Fall Risk/Safety____________________________________________ (High I Moderate I Low)

[ ] Assistance walking [ ] Assistance standing

Mobility: _________________________________________________ (High I Moderate I Low)

[ ] Transfer Belt [ ] Hoyer lift [ ] Sliding Board [ ] Wheel Chair

Positioning: ________________________________________ [ ] Every 1-2hrs [ ] Every 2-4hrs

Toileting: _______________________________________________ [ ] Catheter [ ] Suprapubic

[ ] Skin irritations [ ] Bowel elimination (Enema’s) [ ] Peri care

Light housekeeping/Laundry: ______________________________________________________

[ ] Garbage [ ] Washing Dishes [ ] Bathrooms [ ] Integral to personal care

Eating: ________________________________________________________________________

[ ] Assistance eating/drinking [] Preparing [] Meal [] Grocery Shopping

Bathing: _______________________________________________________________________

[ ] Showering/ Bath assistance [ ] Drying [ ] Moisturizing

Grooming: _____________________________________________________________________

[ ] Personal Hygiene [] Hair care [] Oral care [] Shaving [] Nail care [] Contacts

Dressing: ______________________________________________________________________

[ ] Assistance dressing [ ] Lay out clothing [] Change clothing [] Orthotics

Behaviors: _____________________________________________________________________

[ ] Redirecting [] Observing [] Monitoring & Documenting behavior