Patient Name
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First Name
Last Name
Does Patient have an Advanced Care Directive on hand (NO CODE/DO NOT RESUSCITATE - usually posted on the refrigerator)?
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Diagnosis (Physical) - list any diagnosed conditions: Hospice, Stroke, Diabetes, Parkinson’s, Cancer (what type & stage), Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Multiple Sclerosis (MS); 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:
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Diagnosis (Cognition) - list any mental diagnosis: Dementia, Alzheimer’s, Sundowners or any psychosis (Schizophrenia, Bi-Polar), including symptoms to look for (forgetful, mood swings), general disposition and special care instructions:
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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 describe how medications distributed (module, blister pack, pill bottles, patches, injections, syringes); any PRN (as needed) medications; frequency administered (EX: morning, lunch, dinner, bedtime; PRN frequency); where medications are stored (lock box with code, cupboard); how much oversite & assistance is required (reminders, physical help); who orders medications and how delivered:
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:
Household Instructions: trash removal and recycling (what day/time, where); laundry (on-site or off-site, frequency, how paid); shopping (who, when and how paid); pets and pet care needed (feeding, waste cleanup):
Contacts (list any additional contacts, especially spouse, family, DPA, Payee or other Responsible Party representatives, household information - full name, cell, email):
Directions: any special driving or parking directions, landmarks, building or door key access codes, etc.):
Notes (list caregiver preferences - gender, age, ethnicity, personality, smoker, chemical allergies; desired schedule - days & times, flexibility options):
