AIDE CARE PLAN
Patients Name:
*
DOB:
*
-
Month
-
Day
Year
Date
Street Address:
*
City:
*
State:
*
Zip:
*
Phone Number
*
Emergency Contact/Relationship
Relationship with Patient:
*
Phone Number
*
Days Needed:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Times Needed:
*
Client Dx/Problem
PRECAUTIONARY AND OTHER PERTINENT INFORMATION - Check all that apply
Type a question
*
Lives alone
Lives with other
Alone during the day
Bed bound
*
Bed rest/BRPs
Up as tolerated
*
Partial weight bearing
R
L
*
Non - weightbearing:
R
L
*
Fall precautions
Speech/Communicationdeficit
*
Vision deficit:
Glasses
Contacts
*
Hearing deficit:
Hearing Aid
*
Dentures:
Upper
Lower
*
Forgetful/Confused
Urinary catheter
*
Diabetic
Do not cut nails
Diet:
Seizure precaution
Prone to fractures
*
Diabetic
Do not cut nails
Diet:
Seizure precaution
Prone to fractures
Assignment
Bath
*
Every
Visit
Wk
Tub/Shower
Bed Bath
Partial/Complete
Assist Bath Chair
Other Comments/Instructions
Personal Care
*
Every
Visit
Wk
Personal Care
Assist w/ dressing
Groom Hair
Shampoo
Skin Care
Teeth Care
Other (specify):
Other Comments/Instructions
Procedures
*
Every
Visit
Wk
Toileting Assist
Catheter Care
Ostomy Care
Medication Reminder
Other (specify):
Other Comments/Instructions
Activity
*
Every
Visit
Wk
Assist w/ Ambulation
W/C / Walker / Cane
Mobility Assist
Chair/Bed
Shower/Tub
Exercise -Per
PT/OT
Care Plan
Other (specify):
Other Comments/Instructions
Nutrition
*
Every
Visit
Wk
Meal Preparation
Assist with Feeding
Limit/Encourage
Fluids
Grocery Shopping
Other (specify):
Other Comments/Instructions
Other
*
Every
Visit
Wk
Laundry
Light Housekeeping
Bedroom/Bathroom/
Kitchen/Bed Linen
Equipment Care
Transportation
Other Comments/Instructions
Employee Signature:
*
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