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PLAN OF CARE : NON-MEDICAL IN HOME CARE

Date: Client Name:

Client Phone #:

Address:

City:

State:

Zip:

Diagnosis:

Allergies/Restrictions:

Age:

Birthdate:

DNR:

Yes No

Height:

Weight:

Type of Service:

Service Days:

Service Hours:

COMPANION CARE PERSONAL CARE

SAFETY Companionship & Safety

Per visit Per request Reading Hobbies Mental Stimulation Alzheimers Dementia Other:

Bathing

None Shower Sponge bath Tub bath

Shampoo Comb Monitoring Only Stndby/Asst Shaving (electric shaver only) Other:

Safety Measures

Siderails Grab bars Pathways clear Emergency Alert System Other:

Meal Preparation:

Per visit Per request Cook meals: Assist with Feeding Nothing by mouth Dietary restrictions: Favorite Foods: Notes:

Dressing:

Total Assistance Partial Assistance Assist w/ socks & shoes

Equipment & Supplies

None Commode Walker Urinal Cane Hospital Bed Wheelchair Hoyer Lift Gait Belt Incontinence Gloves products used Other:

Elimination

Per visit Per request Check bowel movement Change disposables/pad if soiled Incontinent of urine bowel Foley catheter Foley cath care with soap/water External catheter Notes/Other:

Light Housekeeping:

Per visit Per request Vacuuming:

AREAS: Dusting:

AREAS: Make Bed:

NOTES: Tidy Common Areas:

AREAS:

Other:

Smoking: Alcohol Use:

Ambulation / Assist / Transfer

Ambulatory Bedridden Walker/Cane Wheelchair

Walks with Assistance Standby / Assist Fall risk Needs lifting from bed/chair Partial or Full Transfers Reposition/Notes:

Pet Care:

Required Pet Care: Pets Type: Describe:

Pet’s Name(s):

Laundry:

Per visit Per request Wash Dry Ironing: Change Bed Linens

Mental Status:

Hearing:

Vision:

Medication:

Medication Reminders Self Managed Details/Notes:

Oral Care

None Brush teeth Dentures?: Yes No

Notes:

Sun From To

Mon From To

Tue From To

Wed From To

Thu From To

Fri From To

Sat From To

Transportation:

Client vehicle Employee vehicle Accompany client if family

drives Special Instructions:

Other:

Other:

Other:

Other: