(615) 717-0077
(615) 424-4376
(615) 891-7685
devotedhcinc@gmail.com
1653 Bridgecrest Dr, Antioch, TN 37013
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Home
About
Services
Companionship
Home Health Aide
Personal Care Assistant
Homemaker
Companion/Sitter
Live-In Caregiver
Blog
Service Areas
Careers
Forms
Client Forms
Staff Forms
Resources
Contact
Client Care Plan
Forms
Client Care Plan
Client name:
DOB:
Gender
Male
Female
MR #:
SOC Date:
MM slash DD slash YYYY
Client address:
Client phone number:
Lives with:
Relationship to client:
Advance Directive:
Yes
No
Emergency contact:
(name, relationship, phone number)
Evacuation plan:
Choose priority level below
Priority level:
I
II
III
IV
Diagnosis:
Allergies:
Diet (specify):
Assistive devices:
Hearing aids
R
L
Glasses
Dentures
Cane
Walker
Wheelchair
Crutches
Hospital bed
Side Rails
Gait Belt
Slide board
Hoyer lift
Shower chair
Bedside commode
3n1
Ostomy equipment
Prostatic device
Splint
Cast
Brace
TED hose
Other
Other
Psychosocial:
Alert
Oriented
Confused
Forgetful
Wanders
Functional limitations:
Hard of Hearing
Legally Blind
Primary language
Non-verbal communication
Amputee (site)
Paralyzed (site)
Incontinence
Bladder
Bowel
Other
Primary language
Amputee (site)
Paralyzed (site)
Other
Discipline to be provided:
Duration of services:
Frequency of visits:
Special requests from client or family:
Supervisor name and number:
Frequency of supervisory visits:
Goals for care:
Client personal care/ADLs will be provided at an optimum level of personal hygiene.
Client will receive assistance with personal care/ADLs to maintain an optimum level of personal hygiene.
Client will become independent in personal care/ADLs within ____________ Wk/Mo.
Client will be maintained in the home setting.
Client will have home cleanliness maintained.
Other
Client will become independent in personal care/ADLs within ____________ Wk/Mo.
Other
Rehabilitation potential:
Care plan completed by:
Signature/Title
Date
MM slash DD slash YYYY
Employee providing client care reviewed the plan of care prior to providing care:
Name(print)/Signature of the employee
Date
MM slash DD slash YYYY
The admission assessment has defined that the client is cognizant and functionally able to determine what kind of bath he/she wants.
Yes
No
Personal Care Tasks
Days to be performed
1. Total bed bath
M
T
W
Th
F
Sa
Su
2. Assist bed bath
M
T
W
Th
F
Sa
Su
3. Assist shower
M
T
W
Th
F
Sa
Su
4. Assist tub
M
T
W
Th
F
Sa
Su
5. Sponge bath
M
T
W
Th
F
Sa
Su
6. Shampoo
M
T
W
Th
F
Sa
Su
7. Conditioner
M
T
W
Th
F
Sa
Su
8. Comb/brush hair
M
T
W
Th
F
Sa
Su
9. Brush teeth
M
T
W
Th
F
Sa
Su
10. Clean dentures
M
T
W
Th
F
Sa
Su
11. Apply lotion to skin
M
T
W
Th
F
Sa
Su
12. Dress
M
T
W
Th
F
Sa
Su
13. Shave
Safety razor
Electric
M
T
W
Th
F
Sa
Su
14. Nail care
Clean
File
M
T
W
Th
F
Sa
Su
15. Medications
Remind
Assist with self-administered meds
M
T
W
Th
F
Sa
Su
16. Apply
M
T
W
Th
F
Sa
Su
17. Remove
M
T
W
Th
F
Sa
Su
Toilet/Elimination tasks
18. Urinal
M
T
W
Th
F
Sa
Su
19. Bedpan
M
T
W
Th
F
Sa
Su
20. Commode
M
T
W
Th
F
Sa
Su
21. Toilet
M
T
W
Th
F
Sa
Su
22. Incontinence brief
M
T
W
Th
F
Sa
Su
23. Incontinence care
M
T
W
Th
F
Sa
Su
24. Empty urinary bag
M
T
W
Th
F
Sa
Su
25. Empty ostomy bag
Empty ostomy bag
Rinse ostomy bag
M
T
W
Th
F
Sa
Su
Special Instructions
26. Vitals signs
Temp
Pulse
Resp.
B/P
M
T
W
Th
F
Sa
Su
27. Weigh
M
T
W
Th
F
Sa
Su
28. Other
M
T
W
Th
F
Sa
Su
Nutrition tasks
Days to be performed
29. Prepare meal
B
L
D
Snack
M
T
W
Th
F
Sa
Su
30. Total feed
M
T
W
Th
F
Sa
Su
31. Assist with feeding
M
T
W
Th
F
Sa
Su
32. Restrict fluids: Amount for 24 hours:
M
T
W
Th
F
Sa
Su
Mobility tasks
33. Bedrest: Turn q hr
M
T
W
Th
F
Sa
Su
34. Assist to transfer
M
T
W
Th
F
Sa
Su
35. Assist to ambulate
M
T
W
Th
F
Sa
Su
36. Wheelchair
M
T
W
Th
F
Sa
Su
37. Walker
M
T
W
Th
F
Sa
Su
38. Cane
M
T
W
Th
F
Sa
Su
39. Crutches
M
T
W
Th
F
Sa
Su
40.
Exercise
Range of motion
M
T
W
Th
F
Sa
Su
Precautions
41. Infection control: Hand washing; Standard recautions
M
T
W
Th
F
Sa
Su
42. Choking
M
T
W
Th
F
Sa
Su
43. Bleeding
M
T
W
Th
F
Sa
Su
44. Oxygen safety
M
T
W
Th
F
Sa
Su
45. Fall prevention
M
T
W
Th
F
Sa
Su
Support Service task
46. Clean client areas
M
T
W
Th
F
Sa
Su
47. Change bed linens
M
T
W
Th
F
Sa
Su
48. Make client bed
M
T
W
Th
F
Sa
Su
49. Client laundry
M
T
W
Th
F
Sa
Su
50. Shopping for:
M
T
W
Th
F
Sa
Su
51. Errands to:
M
T
W
Th
F
Sa
Su
52. Transportation to:
M
T
W
Th
F
Sa
Su
53. Other
M
T
W
Th
F
Sa
Su
Report the following changes to the Supervisor (list):
The client or legal representative participated in development of the care plan.
Yes
No
Explain why if no:
The care plan was discussed with the discipline(s) that will be providing care.
Yes
No
Explain why if no:
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