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Y [ 0 [ 7Y R ` kE ` Y ` 0 Y d D D S D D D D D 'Z 'Z S D D D [ D D D D ` D D D D D D D D D : R E S I D E N T N A M E
F O R M T E X T P R O V I D E R N A M E
F O R M T E X T C U R R E N T D A T E
F O R M T E X T D A T E E N T E R E D
F O R M T E X T D A T E D I S C H A R G E D
F O R M T E X T D A T E O F B I R T H
F O R M T E X T A G E
F O R M T E X T S S N
F O R M T E X T P R I M A R Y L A N G U A G E
F O R M T E X T N A M E & A D D R E S S O F I N T E R E S T E D P A R T Y ( G U A R D I A N , P O A , F A M I L Y )
F O R M T E X T H O M E P H O N E
F O R M T E X T W O R K P H O N E
F O R M T E X T N A M E O F P H Y S I C I A N O R M E D I C A L G R O U P
F O R M T E X T P H O N E
F O R M T E X T F A X
F O R M T E X T P H A R M A C Y N A M E
F O R M T E X T P H O N E
F O R M T E X T F A X
F O R M T E X T N A M E O F D E N T I S T O R D E N T A L G R O U P
F O R M T E X T P H O N E
F O R M T E X T F A X
F O R M T E X T A D V A N C E D I R E C T I V E Y E S F O R M C H E C K B O X N O
F O R M C H E C K B O X I F Y E S , S P E C I F Y T Y P E ( S )
F O R M T E X T L E G A L D O C U M E N T S Y E S F O R M C H E C K B O X N O F O R M C H E C K B O X I F Y E S , S P E C I F Y T Y P E ( S )
F O R M T E X T C U R R E N T M E D I C A L S T A T U S : F O R M T E X T
M E D I C A L H I S T O R Y : F O R M T E X T
Y E S N O C O M M E N T S S P E C I A L T Y N E E D S F O R M C H E C K B O X F O R M C H E C K B O X F O R M T E X T D E M E N T I A F O R M C H E C K B O X F O R M C H E C K B O X F O R M T E X T M E N T A L H E A L T H F O R M C H E C K B O X F O R M C H E C K B O X F O R M T E X T D E V E L O P M E N T A L D I S A B I L I T Y F O R M C H E C K B O X F O R M C H E C K B O X F O R M T E X T
E M E R G E N C Y E V A C U A T I O N Y E S N O I N D E P E N D E N T R e s i d e n t i s P h y s i c a l l y & m e n t a l l y c a p a b l e o f s a f e l y g e t t i n g o u t o f t h e h o m e w i t h o u t t h e a s s i s t a n c e o f a n o t h e r i n d i v i d u a l o r t h e u s e o f m o b i l i t y a i d s . ( T h e r e s i d e n t i s c o n s i d e r e d i n d e p endent if capable of getting out after one verbal cue) FORMCHECKBOX FORMCHECKBOX ASSISTANCE REQUIREDResident Is not physically or mentally capable of getting out of the house without assistance from another individual or mobility aids. FORMCHECKBOX FORMCHECKBOX SPECIAL INSTRUCTIONS: FORMTEXT
C A R E A N D S E R V I C E S R E S I D E N T S T R E N G T H S / W H A T R E S I D E N T P R E F E R S T O D O I N D E P E N D E N T L Y W H A T P R O V I D E R / C A R E G I V E R / S U P P O R T P E R S O N D O E S / W H E N & H O W C O M M U N I C A T I O N : S P E E C H / H E A R I N G / V I S I O N
Y e s
N o P r o b l e m s w i t h s p e e c h
D e s c r i b e : F O R M T E X T
F O R M C H E C K B O X F O R M C H E C K B O X F O R M T E X T
F O R M T E X T H e a r i n g p r o b l e m s
D e s c r i b e / a i d : F O R M T E X T
F O R M C H E C K B O X F O R M C H E C K B O X V i s u a l p r o b l e m s
D e s c r i b e / a i d : F O R M T E X T
F O R M C H E C K B O X F O R M C H E C K B O X T e l e p h o n e U s e
F O R M C H E C K B O X I n d e p e n d e n t F O R M C H E C K B O X A s s i s t a n c e F O R M C H E C K B O X D e p e n d e n t L a n g u a g e : F O R M T E X T
D e s c r i b e M E D I C A T I O N M A N A G E M E N T :
Self Administration (Check all that apply) FORMCHECKBOX Oral
FORMCHECKBOX Topical
FORMCHECKBOX Eye drops/ointments
FORMCHECKBOX Inhalers FORMCHECKBOX Sprays
FORMCHECKBOX Injections
FORMCHECKBOX Allergy Kits
FORMCHECKBOX Keep Own Meds FORMTEXT
F O R M T E X T S E L F M E D I C A T I O N W / A S S I S T A N C E F O R M C H E C K B O X O r a l
F O R M C H E C K B O X T o p i c a l
F O R M C H E C K B O X E y e d r o p s / o i n t m e n t s
F O R M C H E C K B O X I n h a l e r s F O R M C H E C K B O X S p r a y s
F O R M C H E C K B O X A l l e r g y K i t s
F O R M C H E C K B O X M e d s O r g a n i z e r
F O R M C H E C K B O X E q u i p m e n t : F O R M T E X T
F O R M T E X T
F O R M T E X T C A R E A N D S E R V I C E S R E S I D E N T S T R E N G T H S / W H A T R E S I D E N T P R E F E R S T O D O I N D E P E N D E N T L Y W H A T P R O V I D E R / C A R E G I V E R / S U P P O R T P E R S O N D O E S / W H E N & H O W A DMINISTRATIONNurse Delegated? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Oral
FORMCHECKBOX Topical
FORMCHECKBOX Eye drops/ointments
FORMCHECKBOX Inhalers
FORMCHECKBOX Sprays
FORMCHECKBOX Allergy Kits
FORMCHECKBOX Meds Organizer
FORMCHECKBOX Equipment: FORMTEXT
F O R M T E X T
F O R M T E X T I n j e c t i o n s F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o I f y e s :
F O R M C H E C K B O X S u r r o g a t e
F O R M C H E C K B O X B y f a m i l y
F O R M C H E C K B O X L i c e n s e d p r o f e s s i o n a l M e d i c a t i o n p l a n s w h e n r e s i d e n t n o t i n h o m e :
F O R M T E X T
T R E A T M E N T / P R O G R A M S / T H E R A P I E S F O R M T E X T
F O R M T E X T H e a l t h i s s u e s t o m o n i t o r : Y e s N o O x y g e n U s e F O R M C H E C K B O X F O R M C H E C K B O X P a i n F O R M C H E C K B O X F O R M C H E C K B O X W e i g h t L o s s / G a i n F O R M C H E C K B O X F O R M C H E C K B O X P r o g r a m s t h e r e s i d e n t a t t e n d s , s u c h a s a d u l t d a y h e a l t h
N u r s i n g C o n s u l t a t i o n / T r e a t m e n t s Y e s N o R N D e l e g a t i o n F O R M C H E C K B O X F O R M C H E C K B O X W h a t t a s k s : F O R M T E X T
C o n s e n t F O R M C H E C K B O X F O R M C H E C K B O X P h y s i c a l E n a b l e r s : F O R M T E X T
C A R E A N D S E R V I C E S R E S I D E N T S T R E N G T H S / W H A T R E S I D E N T P R E F E R S T O D O I N D E P E N D E N T L Y W H A T P R O V I D E R / C A R E G I V E R / S U P P O R T P E R S O N D O E S / W H E N & H O W P S Y C H / S O C I A L / C O G N I T I V E S T A T U S Y e s N o W h a t r e s i d e n t d o e s
D e s c r i b e b e h a v i o r s b e s p e c i f i c :
F O R M T E X T D e s c r i b e s p e c i f i c n o n - m e d i c a t i o n ( b e h a v i o r a l / e n v i r o n m e n t a l ) i n t e r v e n t i o n s t o a d d r e s s t h e s y m p t o m s :
F O R M T E X T
S l e e p d i s t u r b a n c e F O R M C H E C K B O X F O R M C HECKBOX Memory impairment (Short-term) FORMCHECKBOX FORMCHECKBOX Memory impairment (Long-term) FORMCHECKBOX FORMCHECKBOX Decision making FORMCHECKBOX FORMCHECKBOX Disruptive behavior FORMCHECKBOX FORMCHECKBOX Assaultive FORMCHECKBOX FORMCHECKBOX Resistive FORMCHECKBOX FORMCHECKBOX Depression FORMCHECKBOX FORMCHECKBOX Anxiety FORMCHECKBOX FORMCHECKBOX Disorientation FORMCHECKBOX FORMCHECKBOX Wandering in home FORMCHECKBOX FORMCHECKBOX Exit seeking FORMCHECKBOX FORMCHECKBOX Hallucinations FORMCHECKBOX FORMCHECKBOX Delusions
If yes, describe: FORMCHECKBOX FORMCHECKBOX Requires psychopharmacological medications
If yes, describe symptoms for each medication: FORMTEXT F O R M C H E C K B O X F O R M C H E C K B O X U N I V E R S A L P R E C A U T I O N S F O R M T E X T C a r e g i v e r w i l l u s e l a t e x / p l a s t i c g l o v e s w h e n i n c o n t a c t w i t h a n y s e c r e t i o n s t o p r e v e n t s p r e a d o f i n f e c t i o n . T h o r o u g h h a n d w a s h i n g w i t h s o a p w i l l b e d o n e b e f o r e a n d a fter gloving. Gloves will be put on and discarded at the end of each task.
CARE AND SERVICESRESIDENT STRENGTHS/WHAT RESIDENT PREFERS TO DO INDEPENDENTLYWHAT PROVIDER/CAREGIVER/SUPPORT PERSON DOES/WHEN & HOWMOBILITY
In room & immediate living environment:
FORMCHECKBOX Independent FORMCHECKBOX Assistance FORMCHECKBOX Dependent FORMTEXT F O R M T E X T O u t s i d e o f i m m e d i a t e l i v i n g e n v i r o n m e n t ( t o i n c l u d e o u t d o o r s ) :
F O R M C H E C K B O X I n d e p e n d e n t F O R M C H E C K B O X A s s i s t a n c e F O R M C H E C K B O X D e p e n d e n t E q u i p m e n t : F O R M T E X T
P r e f e r e n c e s / C h o i c e s : F O R M T E X T
B E D M O B I L I T Y / T R A N S F E R
F O R M C H E C K B O X I n d e p e n d e n t F O R M C H E C K B O X A s s i s t a n c e F O R M C H E C K B O X D e p e n d e n t F O R M T E X T F O R M T E X T S k i n c a r e d u e t o i n a b i l i t y t o p o s i t i o n s e l f : F O R M T E X T E q u i p m e n t / s u p p l i e s : F O R M T E X T
R i s k f o r f a l l s : F O R M T E X T P r e f e r e n c e s : F O R M T E X T E n a b l e r s : F O R M T E X T
S a f e t y a s s e s s m e n t , a l t e r n a t i v e s e x p l o r e d ; h o w t o k e e p r e s i d e n t s a f e : F O R M T E X T
N i g h t t i m e c a r e n e e d s : F O R M T E X T
E A T I N G
F O R M C H E C K B O X I n d e p e n d e n t F O R M C H E C K B O X A s s i s t a n c e F O R M C H E C K B O X D e p e n d e n t F O R M T E X T F O R M T E X T S p e c i a l d i e t / s u p p l e m e n t s : F O R M T E X T
E a t i n g h a b i t s F O R M T E X T
F o o d a l l e r g i e s F O R M T E X T P r e f e r e n c e s / e q u i p m e n t F O R M T E X T C A R E A N D S E R V I C E S R E S I D E N T S T R E N G T H S / W H A T R E S I D E N T P R E F E R S T O D O I N D E P E N D E N T L Y W H A T P R O V I D E R / C A R E G I V E R / S U P P O R T P E R S O N D O E S / W H E N & H O W T O I L E T I N G / C O N T I N E N C E I S S U 2 4 6 @ B b d x z | 0 2 F H J T V X Z úzj js hw 5CJ U\ j hw 5CJ U\$j hw 5CJ U\mH nH u j hw 5CJ U\j hw 5CJ U\hw 5CJ \
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F O R M C H E C K B O X I n d e p e n d e n t F O R M C H E C K B O X A s s i s t a n c e F O R M C H E C K B O X D e p e n d e n t F O R M T E X T F O R M T E X T B l a d d e r i n c o n t i n e n c e F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X O c c a s i o n a l
B o w e l i n c o n t i n e n c e F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o F O R M C H E C K B O X O c c a s i o n a l S k i n c a r e d u e t o b o w e l / b l a d d e r i n c o n t i n e n c e : F O R M T E X T E q u i p m e n t : F O R M T E X T
P r e f e r e n c e s : F O R M T E X T
D R E S S I N G
F O R M C H E C K B O X I n d e p e n d e n t F O R M C H E C K B O X A s s i s t a n c e F O R M C H E C K B O X D e p e n d e n t F O R M T E X T F O R M T E X T E q u i p m e n t : F O R M T E X T
P r e f e r e n c e s : F O R M T E X T
P E R S O N A L H Y G I E N E
F O R M C H E C K B O X I n d e p e n d e n t F O R M C H E C K B O X A s s i s t a n c e F O R M C H E C K B O X D e p e n d e n t F O R M T E X T F O R M T E X T O r a l h y g i e n e , i n c l u d i n g d e n t u r e s : F O R M T E X T
W h e n a n d h o w o f t e n : F O R M T E X T
P r e f e r e n c e s : F O R M T E X T
B A T H I N G
F O R M C H E C K B O X I n d e p e n d e n t F O R M C H E C K B O X A s s i s t a n c e F O R M C H E C K B O X D e p e n d e n t F O R M T E X T F O R M T E X T
H o w o f t e n : F O R M T E X T
W h e n : F O R M T E X T
E q u i p m e n t : F O R M T E X T
P r e f e r e n c e s : F O R M T E X T
C A R E A N D S E R V I C E S R E S I D E N T S T R E N G T H S / W H A T R E S I D E N T P R E F E R S T O D O I N D E P E N D E N T L Y W H A T P R O V I D E R / C A R E G I V E R / S U P P O R T P E R S O N D O E S / W H E N & H O W B O D Y C A R E ( F o o t c a r e , s k i n c a r e , n a i l c a r e , r a n g e o f m o t i o n , d r e s s i n g c h a n g e s )
F O R M C H E C K B O X I n d e p e n d e n t F O R M C H E C K B O X A s s i s t a n c e F O R M C H E C K B O X D e p e n d e n t F O R M T E X T F O R M T E X T
F o o t c a r e : F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
S k i n c a r e : F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
H o w o f t e n : F O R M T E X T
S k i n p r o b l e m s : F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
D e s c r i b e : F O R M T E X T D r e s s i n g c h a n g e s : F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
N u r s e d e l e g a t e d : F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
P r e f e r e n c e s : F O R M T E X T M A N A G I N G F I N A N C E S
F O R M C H E C K B O X I n d e p e n d e n t F O R M C H E C K B O X A s s i s t a n c e F O R M C H E C K B O X D e p e n d e n t
W h o m a n a g e s f i n a n c e s : F O R M T E X T
F i n a n c i a l r e c o r d s : F O R M T E X T
P r e f e r e n c e s : F O R M T E X T F O R M T E X T F O R M T E X T S H O P P I N G
F O R M C H E C K B O X I n d e p e n d e n t F O R M C H E C K B O X A s s i s t a n c e F O R M C H E C K B O X D e p e n d e n t
S p e c i a l t r a n s p o r t a t i o n n e e d s : F O R M T E X T
H o w o f t e n : F O R M T E X T
P r e f e r e n c e s : F O R M T E X T
F O R M T E X T F O R M T E X T T R A N S P O R T A T I O N
F O R M C H E C K B O X I n d e p e n d e n t F O R M C H E C K B O X A s s i s t a n c e F O R M C H E C K B O X D e p e n d e n t
M e d i c a l s e r v i c e s :
S p e c i a l t r a n s p o r t a t i o n n e e d s : F O R M T E X T
E q u i p m e n t : F O R M T E X T
H o w o f t e n : F O R M T E X T
P r e f e r e n c e s : F O R M T E X T
F O R M T E X T F O R M T E X T A C T I V I T I E S / S O C I A L N E E D S
F O R M C H E C K B O X I n d e p e n d e n t F O R M C H E C K B O X A s s i s t a n c e F O R M C H E C K B O X D e p e n d e n t
I n t e r e s t s / A c t i v i t i e s / R e l i g i o u s A c t i v i t i e s : F O R M T E X T
S o c i a l / C u l t u r a l T r a d i t i o n s / P r e f e r e n c e s : F O R M T E X T
F a m i l y / F r i e n d s / R e l a t i o n s h i p s : F O R M T E X T
E m p l o y m e n t S u p p o r t : F O R M T E X T
C l u b s / G r o u p s / D a y H e a l t h :
E m e r g e n c y N u m b e r s P r o v i d e d : F O R M T E X T
S p e c i a l A r r a n g e m e n t s : F O R M T E X T
P a r t i c i p a t i o n I s s u e s : F O R M T E X T
F O R M T E X T F O R M T E X T S M O K I N G
F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o
S a f e t y C o n c e r n s : F O R M T E X T
P r e f e r e n c e s : F O R M T E X T
F O R M T E X T F O R M T E X T C A S E M A N A G E M E N T
F O R M T E X T
F O R M T E X T C o n t a c t t h e c a s e m a n a g e r w h e n :
T h e r e s i d e n t n e e d s a s s i s t i v e d e v i c e o r o t h e r s e r v i c e s t o m e e t t h e n e e d s
W h e n y o u n e e d h e l p w i t h t h e c a r e p l a n
S i g n i f i c a n t c h a n g e s w i t h t h e c o n d i t i o n / n e e d s t h a t n e c e s s i t a t e c h a n g e s w i t h t h e c a r e p l a n
O T H E R I S S U E S / C O N C E R N S / P R O B L E M S
F O R M T E X T
F O R M T E X T F O R M T E X T
W A C 3 8 8 - 7 6 - 1 0 3 5 5 - N e g o t i a t e d C a r e P l a n . B r i e f i n s t r u c t i o n s b a s e d o n W A C
D e v e l o p e d w i t h i n 3 0 d a y s o f a d m i s s i o n b a s e d o n t h e A s s e s s m e n t a n d t h e P r e l i m i n a r y S e r v i c e P l a n .
D e s c r i b e s / i d e n t i f i e s : ( a ) T h e s e r v i c e s t o b e p r o v i d e d ; ( b ) W h o w i l l p r o v i d e t h e s e r v i c e s ; a n d ( c ) W h e n a n d H o w t h e s e r v i c e s w i l l b e p r o v i d e d .
D e s i g n e d t o m e e t t h e R e s i d e n t s N e e d s , P r e f e r e n c e s , a n d C h o i c e s .
D e v e l o p e d w i t h i n p u t f r o m t h e R e s i d e n t a n d / o r t h e R e s i d e n t s R e p r e s e n t a t i v e / S u r r o g a t e D e c i s i o n M a k e r , a p p r o p r i a t e p r o f e s s i o n a l s , a n d t h e c a s e m a n a g e r , i f a p p l i c a b l e
A g r e e d t o , S i g n e d a n d D a t e d b y t h e R e s i d e n t a n d / o r t h e R e s i d e n t s R e p r e s e n t a t i v e / S u r r o g a t e D e c i s i o n M a k e r , a p p r o p r i a t e p r o f e s s i o n a l s , a n d t h e p r o v i d e r .
T h e s i g n e d c o p y o f t h e p l a n m u s t b e g i v e n t o t h e C a s e M a n a g e r i f R e s i d e n t i s r e c e i v i n g s e r v i c e s p a i d f o r f u l l y o r p a r t i a l l y b y t h e d e p a r t m e n t .
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