Compliments of WSRCC
Personal Data Sheet
Residents Name
Date Entered
Current Date
Code Status FULL CODE
Signature
Age
SSN#
Language
Date of Birth
 Male
Medicare #
 Female
 Right Handed
Medicaid #
Family/POA Name
Smoker
 Yes
 No
Private Insurance #
Provider Name
Signature
Date
Address
Signature
Date
Address
Phone WK
HP
Assessor
Phone WK
Fax
Initial Care Planner
Signature
Date
Address
Signature
Date
Address
Phone WK
Fax
Phone WK
Doctor Name
Nurse Delegator
Address
Address
Phone WK
Fax
Insurance #1
Address
Address
Phone WK
Fax
Funeral Home
Address
Address
Fax
 Yes  No Type
Assessment & Care Plan
Fax
Phone WK
Pharmacy/Insurance #2
Phone WK
Fax
Phone WK
Social Worker/Home Health
Advanced Directive
 Left Handed
DNR
Fax
Phone WK
Informed Consent  Yes  No
Fax
Task
7/14/2017
Compliments of WSRCC
Assessment/Level of Care
Reason for the Assessment (Date & Initial)
Current Prescribed Medications (Include contraindicated medications that
1.
2.
3.
4.
5.
are known to cause adverse reactions or allergies):
Reviewed by physician & signed, see attached
Name
Dose
Admission
Annual
Significant status change / review
Significant status change / review
Quarterly review of assessment
Y
N
Purpose/Diagnosis
Current Medical Diagnosis:
Pertinent Medical History (include previous operations):
H/P Attached or in the Resident file
Y
N
Cognitive Status (Include Depression, Anxiety & Mental Illness) &/or
Significant known Behaviors that may require special care:
Assessment & Care Plan
Allergies:
7/14/2017
Compliments of WSRCC
Assessment/Level of Care
PERSONAL HYGIENE
SPECIALIZED BODY CARE
TOILETING
BATHING
Ability to care for dentures, brush teeth, clean
& apply glasses & hearing aids, etc.
The application of lotions, trim nails, cut hair,
style hair, etc.
Ability to urinate and defecate at will and in
the appropriate place.
 0 Independent - able to do without
assistance or cueing
 1 Supervised Independence - can carry
out skills with verbal reminders only
 2 Minimal - requires verbal cueing, set
up, and stand by assistance
 3 Moderate - requires set up & hands on
assistance with as many as two tasks
 4 Major - requires set up & hands on
assistance with three or more tasks
 5 Total - requires total assistance with
grooming tasks
 0 Independent - able to do without
assistance or cueing
 1 Supervised Independence - can carry
out skills with verbal reminders only
 2 Minimal - requires verbal cueing, set
up, and stand by assistance
 3 Moderate - requires set up & hands on
assistance with as many as two tasks
 4 Major - requires set up & hands on
assistance with three or more tasks
 5 Total - requires total assistance with
grooming tasks


















 0 Independent - continent of bowel and
bladder
 1 Supervised Independence - requires
stand by assist in the bathroom & peri-care
 2 Minimal
occasional
urinary
incontinence, wears protective gear, may
require help with Peri-care up to twice a day
 3 Moderate - requires bladder training
program, protective clothing; verbal reminders
& occasional help with Peri-care
 4 Major - requires frequent trips to
urinate and/or defecate, needs constant
assistance at all times
 5 Total - occasional to frequent
incontinence; Peri-care more than twice daily;
requires assistance at night
Ability to execute bathing & drying a
minimum of two times per week. INCLUDED
is dressing & undressing.
Stand by assist, observe for safety
Assist of 1
 Assist of 2
Glasses
 Visually impaired
Deaf
 Hearing impaired
Hearing Aids
 Left
 Right
Dentures
 Uppers  Lowers
Bridges
 Uppers  Lowers
Gum Disease
 Needs Dental Work
Skin problems
 Dry skin
Itchy Skin
 Bruises easily
Skin allergies
 Soaps/lotions/linens
Rash
 Other
Hx decubitus 1 2 3 4
(circle highest level)
 Location
Preferences/Comments:
Stand by assist, observe for safety
Assist of 1
 Assist of 2
Nails
 Foot Doctor
Makeup
 Lotions
Hair care
 Shave
Preferences/Comments:
 5 points extra for history of urinating
and/or defecating in inappropriate places.











Stand by assist, observe for safety
Assist of 1
 Assist of 2
Catheter
 Size
Bed bag
 Leg bag
Ostomy/Type  Self Care  Assist
Incontinent
 Bowel
 Bladder
Bowel
 Bladder Training
Stress Incont.  Dribbling
Constipation  Laxative use
Chronic Constipation
Depends
 Pads
 0 Independent - only the bathroom
requires cleaning
 1 Supervised Independence - bathes self
without assistance
 2 Minimal - bathes self with help getting
into & out of the tub
 3 Moderate - washes face & hands only,
but cannot bathe rest if body, cooperative
 4 Major - does not bathe self, needs full
bath, cooperative
 5 Total - cannot bathe self, resists efforts
of others to keep clean






Stand by assist, observe for safety
Assist of 1  Assist of 2
Tub
 Shower  Bed Bath
Full
 Partial
Transfer bench needed
Equipment?
Preferences:/Comments:
Preferences/Comments:
Assessment & Care Plan
7/14/2017
Compliments of WSRCC
Assessment/Level of Care
DRESSING
EATING, NUTRITION,
Ability to appropriately dress & undress on
their own from their own wardrobe for the
occasion.
HYDRATION, ORAL
 0 Independent - dresses appropriately
with no assistance
 1 Supervised Independence - may need
some occasional prompting
 2 Minimal - requires some physical
assistance or verbal cues
 3 Moderate - lay out clothes, assist with
shoes & socks & buttoning
 4 Major - requires dressing
 5 Total - requires complete dressing; may
require change of clothes due to soiling


Stand by assist, observe for safety
Assist of 1
 Assist of 2
Yes






No
 Able to dress & undress upper body
 Able to dress & undress lower body
 Able to put on shoes & socks
 Able to put on jewelry
 Able to tie & button as needed
 Needs Ted Hose help (schedule)
Preferences/Comments:
Dietary requirements and dining room needs.
INCLUDED is special preparations.
 0 Independent - no special dietary
requirements or assistance needed
 1 Supervised Independence - requires
some prompting to eat
 2 Minimal - requires food to be cut up or
pureed, mechanical soft, untidy
 3 Moderate - requires special dietary
needs, i. e. supplements, diabetic diet, food
allergies, etc.
 4 Major - requires routine supervision;
intake and diet monitoring; special
observation for Dysphagia
 5 Total - requires hand feeding or
ongoing supervision while eating












Stand by assist, observe for safety
Assist of 1
 Assist of 2
Encourage fluids
 Restrict fluids
Special diet
 Thicken liquids
Low salt
 Low fat
High fiber
 Diabetic
Chewing/swallowing problems
Choking/ Dysphagia/ Aspiration
Risk of dehydration
Tube feeding
 Wt. Loss/Gain
Food Allergies
Prescribed Food Supplements
MOBILITY
Ability to walk or otherwise ambulate
 0 Independent - moves without human or
mechanical assistance
 1 Supervised Independence - moves
without assistance, observe for safety
 2 Minimal - Can move with assistive
devices (walker, cane), may require light
lifting & steadying
 3 Moderate - needs lifting assistance of
another to stand & assistance to walk
 4 Major - needs mechanical &/or physical
assistance & wheelchair
 5 Total - bed bound



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







Stand by assist, observe for safety
Assist of 1
 Assist of 2
Cane
 Walker
Crutches
 Wheelchair
Gait L R
 Mobility Alarm
Number transfers/Amb. a day
Risk of Falls
 Decreased mobility
Motor skills
Bed Bound
 Chair Bound
Restricted ROM/ Contractures
Up at night
 How often
Adaptive equipment
TRANSFERS
Ability to transfer or otherwise safely move
from place to place
 0 Independent - moves without human or
mechanical assistance
 1 Supervised Independence - moves
without assistance, observe for safety
 2 Minimal - requires some assistance
 3 Moderate - needs lifting assistance of
another to stand & assistance to walk
 4 Major - needs physical assistance &
wheelchair
 5 Total - bed bound






Stand by assist, observe for safety
Assist of 1
 Assist of 2
Number of times a day
Mechanical transfer
Lift
 Pivot
Transfer Board
Preferences/Comments:
Preferences/Comments:
 Uses adaptive equipment
Preferences/Comments:
Assessment & Care Plan
7/14/2017
Compliments of WSRCC
Assessment/Level of Care
POSITIONING
COGNITIVE ABILITY
Ability to remain in a sitting or laying position
Mental and emotional faculty of knowing,
including perceiving, thinking, recognizing
and remembering
 0 Independent - able to position self
without human or mechanical assistance
 1 Supervised Independence - positions
self, observe for safety
 2 Minimal - needs some assistance
 3 Moderate - needs assistance
 4 Major - needs physical assistance
several times per day
 5 Total - bed bound








Stand by assist, observe for safety
Assist of 1
 Assist of 2
Number of times a day
Reposition q
hrs
 Daytime
 Night time
Hospital Bed
 Special Mattress
Trapeze
 Bed Rail
Wedge
 Extra Pillows
Foot Cradle
Preferences/Comments:
 0 Independent - alert, no confusion
 1 Supervised Independence - Some early
signs of disorientation or confusion
 2 Minimal
needs
occasional
reorientation easily forgets recent activities
 3 Moderate - requires daily reorientation,
monitoring; mildly depressed
 4 Major - requires frequent daily
reassurance, guidance, direction
 5 Total - tends to wander off premises;
restless during NOC hours
 5 points extra for history of purposeful
escape.
 Stand by assist, observe for safety
 Assist of 1  Assist of 2
 Oriented
Time / place / person (circle)
 Clear speech  Mumbles  Nonverbal
 Cooperative  Uncooperative
 Physically aggressive
 Agitated
 Lethargy
 Restlessness
 Withdrawn  Forgetful
 Dementia
 Memory impairment
 Alzheimer’s  Short  Long Term
 Altered Awareness  Distracted
 Disoriented  Intermittently
When:
 Grief/Loss  Hx Mental Illness
 Psychological Intervention
BEHAVIOR/MANNERISMS
SOCIAL, EMOTIONAL
Appropriate physical/verbal behavior
 0 Independent - cooperative
 1 Supervised Independence - upset at
times, otherwise cooperative and cheerful
 2 Minimal - occasional objectionable
behavior
 3 Moderate - demanding, uncooperative,
offensive, or annoying behavior as often as 23 times/month
 4 Major - displays uncooperative,
offensive, or annoying behavior at least once a
week
 5 Total
habitually
displays
uncooperative, offensive, or annoying
behavior once a day or more
 5 points extra for history of combative
behavior

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


Stand by assist, observe for safety
Assist of 1  Assist of 2
Alert
 Friendly  Euphoric
Cheerful
 Adjusted  Quiet
Demanding  Hostile
 Anxious
Inappropriate  Selfish
 Afraid
Moody
 Dependant  Comatose
Sexual acts  Depressed  Wanders
Manipulator  Paranoid idealization
Resists Care  Hallucinations
Sundowner  Disruptive sleep pattern
Sleeps @ NOC
PREFERENCES / ACTIVITIES
Personal social, emotional preferences &
activities that the resident likes to do.
 0 Independent - socially acceptable,
emotionally stable, entertains self
 1 Supervised Independence - enjoys
activities
 2 Minimal  3 Moderate - dislikes activities
 4 Major
socially
unacceptable,
emotional needs, withdrawn
 5 Total 












Stand by assist, observe for safety
Assist of 1
 Assist of 2
Nickname
Hobbies
Clubs
Religious
Family
 Friends
Kids
 Pets
Visiting with anybody
Smoking
 Sleep
Likes group activities
Dislikes group activities
Other Social Activities
Preferences/Comments:
Preferences/Comments:
(Specific Treatment Noted)
Preferences/Comments:
Assessment & Care Plan
7/14/2017
Compliments of WSRCC
Assessment/Level of Care






0
1
2
3
4
5
EMERGENCY
TRAVELS TO APPOINTMENTS
EVACUATION/SAFETY
Ability
to get to and from Medical
appointments and other places
Fire Evacuation
Independent - Self directed
Supervised Independence
Minimal - Assist, led out
Moderate
Major
Total - Total evacuation
 Stand by assist, observe for safety
 Assist of 1
 Assist of 2
Safety







Falls
Choking
Wandering precautions
Bleeding precautions
Special Oxygen needs
Infection Control
Emergency contacts






0
1
2
3
4
5







Stand by assist, observe for safety
Assist of 1
 Assist of 2
Self transport
 CVAN or Cab
Family transport  Medicaid transport
Assist Resident to appointments
Outpatient PT/OT/ST
Special equipment
Independent - Self directed/Family
Supervised Independence
Minimal - Assist with appointments
Moderate
Major
Total - Total transport
Preferences/Comments:
PT/OT/SPEECH
Outside services from local agencies.
Physical Therapist
LAUNDRY/HOUSEKEEKING
Laundry services for clothing, linens, room
cleaning services, etc.
 0 Independent - Self Care
 1 Supervised Independence  2 Minimal - weekly cleaning
 3 Moderate - cleaning three or more times
per week
 4 Major - Daily cleaning of room and
laundry
 5 Total - Clean room &/or change
bedding or clothing more than 2x/day
Name
Agency
Phone
Occupational Therapist
Name
Agency
Phone
 Wash Clothes
 Sweep floors
 Mop floors
Speech Therapist
Name
Agency
 Wash linens
 Vacuum floors
 Dust room
Preferences/Comments:
Phone
Medical Social Worker
Name
Agency
Phone
Chaplain
Emergency Mental Health Services
Name
Agency
Phone
Preferences/Comments:
Name
Agency
Phone
Caseworker
Name
Agency
Phone
Paralysis
 Left
 Quadriplegia
 Atrophy
Restorative potential
 Good
 Poor
Other
Assessment & Care Plan
 Right
 Paraplegia
 Fair
 Questionable
7/14/2017
Compliments of WSRCC
Nurse Assessment/Level of Care
MEDICATION
Distribution of medications
 0 Independent - no medication except
occasional PRN’s
 1 Supervised Independence - takes own
medicine
 2 Minimal - self medication program with
periodic cueing
 3 Moderate - take up to three different
medications/day with occasional PRN’s; needs
reminders
 4 Major - takes up to six different
medications/day with frequent PRN’s; staff
administered, RN Delegation required
 5 Total - takes seven or more different
medications/day; requires medication at night;
medications might need to be crushed or taken
with applesauce
 Self Administration of Medications
 Remind  Assist
 Time when capable of Self Admin.






Administer (Nurse Delegation required)
Medication allergies
Oxygen
LPM
Inhaler
 Nebulizer
Insulin
 Glucose  Oral
Equipment & supplies
Pharmacy
Address
NURSING INTERVENTION
Need for professional health care and
assessment or Nurse Delegation (excluding
insulin administration)
Nurse Delegation required
 Oral & Topical  Nose, ear, eye drops
 Dressing chgs  Suppositories
 Blood glucose  Gastrostomy
 Medications need to be crushed
 Reason
 Pharmacy has been consulted
RN Delegator
Agency
Phone
Home Care
Agency
Phone
Number of times per week
OTHER NEEDS
 Heart Attack
 Stroke / CVA
 Orthopnea
 O2 Use
 Recent  Wt.  Recent  Wt.
 How much
 Neurological  Respiratory
 Seizures
(Type)
 Foot Drop
 Dizziness
 Numbness
 Peripheral Edema
 Syncope
 Cyanosis
 Hypertension  Hypotension
 Hx.
 Wheezing
 Cough
 Resp. Allergies  Dyspnea
 Hemophtysis  Sputum
 Gripe Equal
 Pupils equal
 Weakness L R Arm Leg Face
 Ataxia
 Balance
 Bruises easily due to meds
STAFFING NEEDS
Additional staff needed to properly care for
the resident so they may “age in place”.
 0 Independent - Self Care
 1 Supervised Independence  2 Minimal -Assistance of one
 3 Moderate - Assistance of two
 4 Major -needs full time additional
staffing
 5 Total - Awake night time staff required
Number of hours a day
Preferences/Comments:
Private Duty
Agency
Phone
Number of times per week
Hospice
Agency
Phone
Number of times per week
Preferences/Comments:
Preferences/Comments:
Phone
Preferences/Comments:
Assessment & Care Plan
7/14/2017
Compliments of WSRCC
Negotiated Care Plan
What the resident does on own
PERSONAL HYGIENE
Ability to care for dentures, brush teeth, glasses, hearing aids, hair, shaving, make-up, etc.










Glasses
 Clean  Apply
Hearing Aids  Clean  Apply
Dentures
 Clean  Apply
Bridges
 Clean  Apply
Brush Teeth  AM
 PM
Mouthwash  Powders or Paste
Wash Face
 Shave Face
Brush or Comb Hair
Deodorant
 Cologne/Perfume
Other
What the Caregiver/Provider does for the resident












Stand by assist, observe for safety
Assist of 1
 Assist of 2
Glasses
 Clean
 Apply
Hearing Aids
 Clean
 Apply
Dentures
 Clean
 Apply
Bridges
 Clean
 Apply
Brush Teeth
 AM
 PM
Mouthwash
 Powders or Paste
Wash Face
 Shave Face
Brush or Comb Hair
Deodorant
 Cologne/Perfume
Other
Preferences:
Preferences:
SPECIALIZED BODY CARE
The application of lotions, trimming nails, etc.





Apply Lotion
Style Hair
Wig
Nail Care
Haircut




Apply Makeup
Perm
Apply Nail Polish
Foot Nail Care







Stand by assist, observe for safety
Assist of 1
 Assist of 2
Apply Lotion
 Apply Makeup
Style Hair
 Perm
Wig
 Apply Nail Polish
Nail Care
 Foot Nail Care
Haircut
Preferences:
Preferences:
Assessment & Care Plan
7/14/2017
Compliments of WSRCC
Negotiated Care Plan
What the resident does on own
TOILETING
Ability to urinate and defecate at will and in the appropriate place


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




Uses toilet on own
Uses Commode
 Urinal
Bed pan
Cares for stoma equipment on own
Wears Depends, pads, etc.
Catheterized and empties on own
Day time
Night time
What the Caregiver/Provider does for the resident
 Stand by assist, observe for safety
 Assist of 1
 Assist of 2
Times/day
 Q4h Reminders to use the bathroom
 Wears Depends, pads, etc.
 Change garments as needed
 Change Bedding  Daily
 Weekly
 Clean stoma equipment
 Clean commode, urinal, bed pan etc.
 Catheter, empty bag as needed
 Other
Preferences:
BATHING
Ability to execute bathing & drying a minimum of two times per week. INCLUDED is dressing
& undressing.
 Set up bathroom with towels, etc.
 Run bath, adjust water & air temp
 Bathe upper body  Bathe lower body
 Bathe back, feet, etc
 Shampoo hair
 Dry hair
 Dry upper body
 Dry lower body
 Dry back, feet, etc  Clean bathroom
How Often?
When?
 AM
 PM












Stand by assist, observe for safety
Assist of 1
 Assist of 2
Set up bathroom with towels, etc.
Run bath, adjust water & air temp
Transfer into & out of bath
Bed Bath
Bathe upper body  Bathe lower body
Bathe back, feet, etc.
Shampoo hair
 Dry hair
Dry upper body
 Dry lower body
Dry back, feet, etc.  Clean bathroom
Other
Preferences:
Preferences:
Assessment & Care Plan
7/14/2017
Compliments of WSRCC
Negotiated Care Plan
What the resident does on own
DRESSING
Ability to appropriately dress & undress on their own from their own wardrobe for the occasion







Pick out own clothes
Dress & undress upper body
Dress & undress lower body
Put on shoes & socks
Put on jewelry
Tie and button as needed
Applies Ted Hose
What the Caregiver/Provider does for the resident
 Stand by assist, observe for safety
 Assist of 1
 Assist of 2
 Pick out clothes
 Dress & undress upper body
 Dress & undress lower body
 Put on shoes & socks
 Put on jewelry
 Tie and button as needed
 Apply Ted Hose
Other
Day Time Wishes?
Night Time Wishes?
Preferences:
EATING, NUTRITION, HYDRATION, ORAL
Dietary requirements and dining room needs. INCLUDED is special preparation of the foods.
 Feed self
 Needs bib
 Drinks on own
 Cuts & butters food on own
Preferences
Assessment & Care Plan
 Serve meals
 In room
 Dining Room







Put on bib
Cut & butter
 Mechanical soft
Uses adaptive equipment
Stand by assist, observe for safety
Assist feeding
 Total Feeder
Encourage fluids
 Restrict Fluids
Special Diet
 Thicken liquids
 Low salt
 Low fat
 High fiber
 Diabetic
 Observe for chewing / swallowing problems
 Observe for Choking / Dysphagia / Aspiration
Other
7/14/2017
Compliments of WSRCC
Negotiated Care Plan
What the resident does on own
MOBILITY
Ability to walk or otherwise ambulate
 Walks on own, NO adaptive equipment
 Cane
 Walker
 Crutches
 Wheelchair
Preferences:
TRANSFERS
Ability to transfer or otherwise safely move from place to place
 Able to transfer on own, NO adaptive equipment
 Transfer Board
 Mechanical Transfer
Preferences:
POSITIONING
Ability to remain in a sitting or laying position
 Able to position on own, NO adaptive equipment
Preferences:
Assessment & Care Plan
What the Caregiver/Provider does for the resident
 Stand by assist, observe for safety
 Assist of 1
 Assist of 2
 Assist with walking
 Assist with walker/cane/crutches
 Assist with wheelchair
 Gait Belt
 Mobility Alarm
 Number transfers/Amb. a day
 Bed Bound
 Chair Bound
 Restricted ROM/ Contractures
 Up at night
 How often
 Adaptive equipment
Other
 Stand by assist for safety
 Assist of 1
 Assist of 2
 Number of times a day
 Mechanical transfer
 Transfer to/from bed
 Transfer to/from chair
 Transfer to/from toilet
 Transfer to/from tub
 Lift
 Pivot
 Transfer Board
Other
 Stand by assist, observe for safety
 Assist of 1
 Assist of 2
 Re-position
Number of times a day
 Reposition q
hrs
 Daytime  Night time
Other
7/14/2017
Compliments of WSRCC
Negotiated Care Plan
What the resident does on own
COGNITIVE ABILITY
Mental and emotional faculty of knowing, including perceiving, thinking, recognizing and
remembering




What the Caregiver/Provider does for the resident
 Stand by assist, observe for safety
 Assist of 1
 Assist of 2
Other
Oriented to Time / Place / Person
Cooperative
 Uncooperative
Physically aggressive
Dementia
 Alzheimer’s
Preferences:
BEHAVIOR/MANNERISMS
Appropriate physical/verbal behavior
 Wanders
 Cheerful
 Stand by assist, observe for safety
 Assist of 1
 Assist of 2
Other
 Sundowner’s
 Depressed
Preferences:
SOCIAL EMOTIONAL PREFERENCES/ACTIVITIES
Personal social preferences that the resident likes to do.




Hobbies
Religious
Activities
Inactivity




 Stand by assist, observe for safety
 Assist of 1
 Assist of 2
Other
Clubs
Visiting
Smoking
Withdrawn
Preferences:
Assessment & Care Plan
7/14/2017
Compliments of WSRCC
Negotiated Care Plan
What the resident does on own
EMERGENCY EVACUATION/SAFETY
Ability to safely evacuate in an emergency & concerns of safety.
Emergency Evacuation




Resident is able to evacuate on own in the event of an emergency
Verbally direct Resident to safety
Assist Resident to safety, hold hand, etc
Evacuate Resident to safety, carry, wheelchair, etc.






Risk of falls
Bruises easily
Choking/Dysphagia
Sundowner
Sex offender
Communicable Disease
What the Caregiver/Provider does for the resident





Stand by assist, observe for safety
Assist of 1
 Assist of 2
Verbally direct Resident to safety
Assist Resident to safety, hold hand, etc
Evacuate Resident to safety, carry, wheelchair, etc.






Stand by assist, observe for safety
Assist of 1
 Assist of 2
Set up appointments
Contact family to transport
Contact CVAN or other public transport
Go to appointments with resident
Safety Issues





Trip hazards
Bleeding
Wandering
Combative towards staff
Pyromania
Preferences:
TRAVELS TO APPOINTMENTS
Ability to get to and from medical appointments and other places.





Self directed to appointments
Family or friends assist with appointments
CVAN or other public transportation
Staff assist with arranging appointments and travel
Staff to set up and go to appointments with Resident
Preferences:
Assessment & Care Plan
7/14/2017
Compliments of WSRCC
Negotiated Care Plan
What the resident does on own
PT/OT/SPEECH
Outside Therapy services &/or exercises provided.
 PT
 OT
 ROM
 Heat
 Remind Resident to exercise
 Speech
 Other
What the Caregiver/Provider does for the resident
 Stand by assist, observe for safety
 Assist of 1
 Assist of 2
 Assist Resident with exercise
 Exercise Resident
 Number of times a week
Other
Preferences:
LAUNDRY/HOUSEKEEPING
Laundry services for clothing, linens, room cleaning services, etc.




Weekly cleaning of the room and laundry
Cleaning three or more times a week
Daily cleaning
Cleaning more than twice a day
Preferences:
MEDICATION
Distribution of medications.




Needs reminders
Assist with medications, open container, preparations, etc.
Self Administer medications on own
Administer medications (requires Nurse Delegation)
 Stand by assist, observe for safety
 Assist of 1
 Assist of 2
 Remind Resident
 Assist with medications, open container, preparations, etc.
 Hand medications to Resident
 Administer medications (requires Nurse Delegation)
Other
Preferences:
NURSING INTERVENTION
 Nurse Delegation
 Private Duty
 Nurse Delegator
 Hospice
Other
 Home Care
 Other
Preferences:
Assessment & Care Plan
7/14/2017
Compliments of WSRCC
Negotiated Care Plan
What the resident does on own
What the Caregiver/Provider does for the resident
OTHER NEEDS




Stand by assist, observe for safety
Assist of 1
 Assist of 2
Seizures
(Type)
O2 Use
STAFFING NEEDS





Number of ADL’s that require Stand By Assist
Number of ADL’s that require 1 Person Assist
Number of ADL’s that require 2 Person Assist
Number of ADL’s that require Total Care
Number of Additional staff needed
Preferences:
Additional staff needed to properly care for the resident so they may “age in place”.
Preferences:
Assessment & Care Plan
7/14/2017
Compliments of WSRCC
List Vital Signs at the time of Assessment
(Optional)
Vital Signs
Vital Signs
Vital Signs
Height
Weight
Height
Weight
Height
Weight
B/P
Pulse
B/P
Pulse
B/P
Pulse
Respiration
Temp
Respiration
Temp
Respiration
Temp
Other
Other
Date
Signature
Date
Vital Signs
Other
Signature
Date
Vital Signs
Signature
Vital Signs
Height
Weight
Height
Weight
Height
Weight
B/P
Pulse
B/P
Pulse
B/P
Pulse
Respiration
Temp
Respiration
Temp
Respiration
Temp
Other
Other
Date
Signature
Date
Vital Signs
Other
Signature
Date
Vital Signs
Signature
Vital Signs
Height
Weight
Height
Weight
Height
Weight
B/P
Pulse
B/P
Pulse
B/P
Pulse
Respiration
Temp
Respiration
Temp
Respiration
Temp
Other
Date
Assessment & Care Plan
Other
Signature
Date
Other
Signature
Date
Signature
7/14/2017
Compliments of WSRCC
Assessment and Negotiated Care Plan Summary Page
(Optional)
Activities of Daily Living (ADL’s)
Personal Hygiene
Comments
Point Score
Additional
Cost
Specialized Body Care
Toileting
Bathing
Dressing
Eating, Nutrition, Hydration, Oral
Mobility
Transfers
Positioning
Cognitive Ability
Behavior/Mannerisms
Social Emotional Preferences/Activities
Emergency Evacuation/Safety
Travels to Appointments
PT/OT/Speech
Laundry/Housekeeping
Medication
Nurse Intervention
Other Needs
Staffing Needs
TOTALS
Assessment & Care Plan
7/14/2017