Patient Name
*
First Name
Last Name
Responsible Party Name (acting on behalf of Patient)
First Name
Last Name
Responsible Party - please describe your relationship to the Patient: family member, friend, Durable Power of Attorney, et
Patient's Contact Information: Please give physical address, mailing address, telephone numbers and email address
Responsible Party's Contact Information: Please give physical address, mailing address, telephone numbers and email address
Does Patient have an Advanced Care Directive on hand (NO CODE/DO NOT RESUSCITATE)?
*
Does Patient require round-the-clock, protective care and observation?
*
Diagnosis: please list any physical diagnosis, communicable infections or diseases pertinent to patient’s care needs (Stroke, Diabetes, Parkinson’s, Cancer, Congestive Heart Failure - CHF, Chronic Obstructive Pulmonary Disease - COPD, STAFF infection, Auto Immune Disease – AIDS, heart attack, paralysis, colostomy, pacemaker, hearing & vision impairments, allergies – chemicals, smoke, pet), including signs and symptoms to be monitored or observed:
*
Cognition & Temperament: Please list mental diagnosis (Dementia, Alzheimer’s, Sundowners, depression or any psychosis), symptoms to look for, general disposition and special care instructions:
*
Emergency Protocols: Please list names and contact information for persons to notify in the event of an emergency. Emergency shut off (electrical box, gas and water valves), fire and smoke detectors, alarms, extinguishers, etc:
*
Medical Team Overseeing Care: Please list all agencies (Home Health, Hospice, PACE), supervising medical professionals (doctor, nurses, social workers), pharmacies and medical supply companies who are overseeing the medical care:
Ambulatory Status: Please list any equipment used (cain, walker, wheelchair, mechanical lifts, gait belt, bedrails), braces or prosthetics to be applied and special care instructions (standby assist, contact guard, independent, fall risk):
Continence and Toileting: Please list any impairment, devises used (urinal, bedpan, catheter, adult diapers, commode); cleaning, storage and any special care instructions (enema or suppositories, frequency of monitoring – also refer to “Skin Care”):
Skin Care: Please list any areas of concern and special care instructions (ulcers or breakdown, lotions, medicated creams, bandages, skin barriers, braces, coverings or equipment):
Turning and Positioning Schedule: For patients requiring turning and positioning day or night, please list frequency of care, protocols followed, equipment used (draw sheets, trapeze, wedges, mechanical lifts, air matts) and any special concerns or care instructions:
Vision, Hearing and Oral Care: Please list any devises used (dentures, glasses, hearing aids) and any special care instructions:
Bathing, Personal Hygiene, Dressing and Grooming: Please list bathing frequency and assistance required, dressing and grooming assistance required (oral, dressing, combing, shaving, makeup); clothing preferences; special toenail care, ear cleaning and haircuts:
Medications & Monitoring: Please list medications, what they’re for, any known side effects; list frequency administered; where stored, how distributed (med module), who fills and orders them:
Vitals, Intake/Output, O2 saturation and Glucose Monitoring: Please list any equipment used, recording procedures and special care instructions:
Dietary and Feeding Concerns: Please list any dietary concerns (Diabetic, choking hazards, dysphasia, food allergies), special foods and supplements to incorporate, food preferences and any physical assistance needed and special care instructions:
Therapy, Exercise and Range of Motion Schedule: Please list any prescribed therapies, exercise and range of motion (activity, frequency, duration), special equipment used, any assistance needed and special care instructions and frequencies:
Hobbies and Interests: Please list client preferences of activities (hobbies, crafts, leisure, recreational and social interests), special equipment used, any assistance needed and special care instructions (transportation arrangements, dates/times for scheduled events):
Caregiver Preferences and Protocols: Are there strong preferences or concerns regarding caregiver gender, age or ethnicity; what personality best suits the patient’s preference (high energy, take initiative, quiet, reserved), does patient prefer caregivers to prepare meals and eat with them, or bring own food and eat in separate room; does patient require caregiver to remain alert overnight or dose while patient sleeps (where):
Household Instructions: Trash removal and recycling, household repairs, food storage, laundry, household chores, supplies and food storage, shopping, appointment calendar, pet care; plant care; visitor protocols; messages, deliveries:
Driving Directions and House Access: Please give driving directions to residence and any special access and key locks/codes to access house:
