NEW CARE PLAN
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1: My History
2: One-on-One Forms
3: Activities Assessment and Plan
4: Daily Activities Preference
5: Preferences for Routine & Activities
6: Resident Care Action Plan
My History
Background
Full Name
Birth date
Birth place
Elementary School
High School
College
Honors
Date of marriage
Place of marriage
Children's names
Military Service
Ocupations
My heritage
What I know about my ancectors and their places of birth?
Languages I speak
Family customs and traditions I would like to perserve
Holiday happenings
My favorite way to celebrate my birthday is
Some of my happiest birthday memories
Halloween costumes I have worn, include
My fondest of all holiday memories is
Activities 1on1 Program
Resident
Room
Reason for program
Motivation
Senory
Cognitive loss
Confined to room / bed
Special need
Other
Date
Approached used
Resident's response
Demographics
Reason for assessment
Initial Assessment
Annual Assessment
Chanage in Condition
Are you a veteran
Yes
No
Material Status
Never Married
Married
Widowed
Separated
Divorced
Voting Status
Registered
Not Registered
Religion
Church
Pastor
Lifetime occupation
Resident Interests
Digital Signature
Date
Clinicial Condition
Digital Signature
Date
Leisure Functioning
Activity Plan
Target groups based on interests or needs
Does the resident need to be on a formal One-on-One Activity Program?
Yes
No
If yes, describe content / focus of the activity
List independent leisure resources needed
List of additional interventions or adaptations needed
Activity related interventions on the Care Plan (may be added at time of Care Plan)
Daily and Activity Preferences PRIMARY Respondent
Indicate primary respondent for daily and activity preferences
Resident
Family
Significant Other
Interview could not be completed
Daily and Activity Preferences STAFF Respondent
Should the staff assessment of daily / Activity Preferences be conducted
Yes
No
Not Assessed
While you are in this community?
Should interview for Daily and Activity preferences be conducted?
Yes
No
Not Assessed
Resident Care Plan
Allergies
DOB
Admission Date
Physcian
Room
Focus
Goal
Interventions
FREQ/RESOLVED
Focus
Goal
Interventions
Freq/Resolved
CARE PLAN HISTORY
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Status
StatusDate
Active
Discharged
Passed
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