Preparation Activities

Appendix

Preparation Activities Appendix D

This HTML document is not a form. Its purpose is to display the information as found on the form for viewing purposes only. if you wish to submit a form, you must use only the PDF version

Home Care Program Care Plan

Client Name:
Band/Settlement:
Date of Birth:
Sex:
Band/Inuit I.D.#:
Address:
Doctor:
Provincial/Territorial Health #:

Allergies:
Diagnosis: Code 1 | Code 2
Review Date:
Level of Care: 1 | 2 | 3 | 4 | 5
Independence:
Support:
Type of Care:

Home Care Services

Type of Service:            Frequency:

Nursing
Personal Care
Home Management
Meal Preparation
Respite Care

Presenting Problems:
Goal Desired Outcomes:
Target Date:
Met/Unmet:
Client/Family/Other Responsibilities:
Home Care Responsibilities:

Home Care Contract

Client's Name:
Primary (or informal) Care giver:
Phone:

Presenting Problem:
Tasks Required:
By Whom:
When:

Signature of client and/or Primary (Informal) Care giver involved

• Home Care Services are provided to assist clients and family to remain living independently as long as possible.
• If you wish any changes to this contract for services please call the Home Care Coordinator.

Date of Reassessment:

Signature of Home Care Coordinator:

Date:

Home Care Program Client Profile

Print Date:
Band/Inuit I.D. #:
Client Name:

Client Strengths:
Client Activities:
Referrals:
Approach:

Approved by: (Signature and Data):

1. ___________
2. ___________
3. ___________
4. ___________

Home Care Program Care Plan Task List

Name:
Band/Settlement:

We have agreed that the Care Plan will include help with the following tasks:

• Personal Care
  Bath
  Oral Care
  Shampoo
  Shave
  Skin Care
  Foot/Nail Care
  Dress
  Comb/Brush/Braid Hair
  
  
• Homemaking Tasks
  Bedroom Cleaned
  Bed Changed
  Sweep/Wash Floors
  Vacuum/Dust
  Bathroom Cleaned
  Kitchen Cleaned
  Fridge Cleaned and/or Defrost
  Stove Top Clean
  Oven Clean
  Laundry
  Other
  Seasonal Cleaning
  Dishes
  Meal Preparation
  Cook Bannock
  Respite/Reassurance Visit
  
  
• Time Frame
  
  
• Client/Family Responsibilities
  
  Home Care Nursing
  Referrals to: (specify)
  Other Services (specify)

Date:
Time:

Comments:

Please notify the home health aide if you will not be home for service.
Please note that clients must supply all cleaning and cooking supplies.

Home Care Assessor:
Date:

Client:
Date:

Home Health Aide Monthly Record

Please fill in Calendar Dates, Times Spent in the Home ("H" for Home Management - "P" for Personal Care - "O" for Other). And Have Clients Initial. Use RED Pen if doing Respite.

Name:
Band/Inuit I.D. #:
Band/Settlement:
Client Identification #:
Date:

• Sunday: am | pm
• Monday: am | pm
• Tuesday: am | pm
• Wednesday: am | pm
• Thursday: am | pm
• Friday: am | pm
• Saturday: am | pm

Please Circle Tasks Provided and Indicate How Often Done

1. Personal Care
   
   1. Bathing, shampooing: _____ times/wk.
   2. Grooming, dressing: _____ times/day/wk.
   3. Feeding: _____ times/day/wk.
   4. Toileting: _____ times/day/wk.
   5. Transferring: _____ times/day/wk.
   6. Routine skin care: _____ times/day/wk.
   7. Turning: _____ times/day/wk.
   8. Backrubs:   _____ times/day/wk.
   9. Activation:   _____ times/day/wk.
   10. Routine foot and: _____ Q wks. nail care
   11. Supervision (Respite) Total Hours This Month: ____
   12. Reassurance visits: _____ times/day/wk.
       
       
2. Home Management
   
   1. General household cleaning Q  : _____wks.
   2. Menu planning Q : _____ wks.
   3. Meal preparation : _____ times/day/wk.
   4. Laundry Q  : _____ wks.
   5. Changing linen Q : _____ wks.
   6. Seasonal cleaning Q : _____wks.
   7. Other (specify)

Home Management ____ Hours Personal Care ____

Hours Other (see H.H.A. notes) ____ Hours Total Hours ___

Visits:
Total Hours:
Attempted Visits:
H.H.A. Signature:
Date:
Supervisor's Signature:
Date:

Name:
Client I.D. #:

A. Physical Health

1. Does your client appear: AS USUAL | WEAKER | IMPROVING
2. Has your client had any new health complaints? Yes | No
3. Have you observed any:
   new health problems: Yes | No
   skin abrasions/rashes: Yes | No
   changes in mobility: Yes | No

B. Mental Health

1. Have you observed any changes in:
   behaviour: Yes | No
   memory: Yes | No
   alertness: Yes | No

C. Personal Care

1. If you are assisting with personal care are you managing safely? Yes | No
2. Do you feel your client neglects personal care? Yes | No
3. Do you recognize a need for:
   additional personal care Yes | No
   additional independence equipment Yes | No

D. Nutrition

1. Have you observed any nutritional problems? Yes | No
2. Does your client receive Meals on Wheels? Yes | No
3. Do you do meal preparation? Yes | No

E. Household Tasks

1. Has the client requested tasks other than on the care plan? Yes | No
2. Are you doing tasks:
   other than on the care plan? Yes | No
   that you feel the client should be able to do on his/her own? Yes | No

F. Communication

1. Have you observed any changes in ability to communicate? Yes | No

G. Support System

1. Are you aware of any changes in the support system? Yes | No

H.H.A. Notes (please comment on changes and/or explain OTHER visits):

Home Health Aide Signature:

Additional Comments Supervisory Staff (please date and sign):

Assessment & Care Coordinator Record

Name:
Band/Inuit I.D. #:
Band/Settlement:
Client Identification #:
Date:

Please fill in calendar dates, primary, secondary and recording times. Identify "A" for Assessment and "C" for Care Coordination.

• Sunday: am | pm
• Monday: am | pm
• Tuesday: am | pm
• Wednesday: am | pm
• Thursday: am | pm
• Friday: am | pm
• Saturday: am | pm

Assessment:

• Hours - Primary | Hours - Secondary | Hours - Recording | TOTAL HOURS

Care Coordination:

• Hours - Primary | Hours - Secondary | Hours - Recording | TOTAL HOURS

Assessments Completed

• Initial | One Month Review | Annual | Reassessment | Other

Total Assessment Visits:
Total Care Coordination Visits:
Total Visits:
Signature:
Date:
Supervisor Signature:

Name:
Band/Inuit I.D. #:

Date:
Summary of Assessment and Care Coordination Duties (Please Sign all Entries)