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Client Name |
Date |
Province |
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Address |
City |
State |
Postal code |
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Phone |
Cell Phone |
Date of Birth |
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Contact Name |
Contact Home Phone |
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Relationship of Contact |
Contact Work Phone |
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Discharge Plans |
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Services to be provided |
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Diagnosis |
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Goals and Objectives of Services |
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Type of Diet |
Allergies |
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Medication |
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Schedule Time |
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Service Start Date |
Duration of Services |
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Mental Status Need |
M |
T |
W |
T |
F |
S |
S |
Hygiene |
M |
T |
W |
T |
F |
S |
S |
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Confused |
Tub Bath |
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Need Reminders |
Shower |
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Require Redirection |
Sponge Bath |
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Need Dementia Assistance |
Bed Bath |
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Emotional Support |
Size Bath |
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Assist with Medication |
Shampoo |
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Other |
Shave |
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Diet/Nutrition |
M |
T |
W |
T |
F |
S |
S |
Assists with dressing |
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Assistance with Eating |
Assist with Grooming |
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Feeding |
Oral Hygiene |
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Encourage Fluids |
Other |
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Diet/ Meal/ Preparation |
Elimination |
M |
T |
W |
T |
F |
S |
S |
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Breakfast/ Lunch/ Dinner |
Assist To Bathroom |
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Snacks |
Assist with Incontinence |
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Household Tasks |
M |
T |
W |
T |
F |
S |
S |
Skin |
M |
T |
W |
T |
F |
S |
S |
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Clean Bedroom |
Lotion to Back |
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Clean Bathroom |
Lotion to Feet |
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Change Linens |
General Skin Care with Lotion |
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Laundry |
File/ Paint Nails |
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Dust |
Assistant with Ted Hose |
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Vaccum |
Other |
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Make Bed |
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Functional Limitations and Aids |
Assistant Measures |
Activity |
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Ataxia |
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Range of Motion |
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Amputation |
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Repositioned Q 2 Hrs (Family Inst.) |
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Contractures |
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Dangled |
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Paralysis |
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Up in Chair |
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Speech |
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Ambition w/Walker/Cane |
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Visual |
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Assistance with 1 2 People |
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Hearing |
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Assistance with Client Exercises |
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Treatments |
Bed Rails Up |
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Procedures |
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Assist Emptying Catheter Bag |
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Equipment Needs |
Assist Emptying Colostomy Bag |
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Assist Emptying Urostomy Bag |
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Assit with Oxygen |
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Monday Additional information |
Signature |
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Tuesday Additional information |
Signature |
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Wednesday Additional information |
Signature |
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Thursday Additional information |
Signature |
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Friday Additional information |
Signature |
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Saturday Additional information |
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Sunday Additional information |
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The undersigned caregiver or provider acknowledges all information provided is a complete and accurate representation of the care and/or services provided. The undersigned also acknowledges they will notify FirstLight HomeCare supervisor or Care Coordinator of any changes in client condition or services required immediately.