NEW CARE PLAN
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1: Activities Assessment and Plan
2: Preferences for Routine & Activities
3: Daily Activities Preference
4: One-on-One Forms
5: Resident Care Action Plan
6: My History
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
Artworks & Crafts
75
Past
Current
Both
Cooking
50
Past
Current
Both
Entertainment / Parties
12
Past
Current
Both
Family / Friends
50
Past
Current
Both
Fitness / Exercise
18,5
Past
Current
Both
Gardening / Outdoors
7,2
Past
Current
Both
Intellectual Games
-4,1
Past
Current
Both
Intergenerational
-15,4
Past
Current
Both
Music / Singing
-26,7
Past
Current
Both
Outings / Trips
-38
Past
Current
Both
Pets / Animals
-49
Past
Current
Both
Reading
-60,6
Past
Current
Both
Religious Services
-71,9
Past
Current
Both
Resident Council
75
Past
Current
Both
Service Work / Helping others
50
Past
Current
Both
Sports
12
Past
Current
Both
Tabel Top Games
50
Past
Current
Both
Movies
75
Past
Current
Both
Needlework
50
Past
Current
Both
News/ Current events
12
Past
Current
Both
Television
50
Past
Current
Both
Others
12
Past
Current
Both
Digital Signature
Date
Clinicial Condition
Visual Impairments
Yes
No
Hearing Impairments
Yes
No
Speech Impairments
Yes
No
Cognitive Impairments
Yes
No
LROM (Arms, hands, or legs)
Yes
No
Diffcult Transfer
Yes
No
Requires assistance with mobility or w/c
Yes
No
Behaviors
Yes
No
Mood issues
Yes
No
Cultural / social issues
Yes
No
Psychosocial issues
Yes
No
Dietary Precautions
Yes
No
Seizure disorder
Yes
No
Restraints release required
Yes
No
Bed Bound
Yes
No
Isolation precautions
Yes
No
Allergies (non-medical related)
Yes
No
Diffculty being understood and / or understanding others
Yes
No
Digital Signature
Date
Leisure Functioning
Resident thoughts on activity programming
In your free time, if you want to do something, where are the supplies, who do you ask, etc: If unaware did staff educate resident
What are your hobbies and unique leisure skills
Ease of interacting with others
Spiritual needs
Preferences for independent leisure activities
What did you do at home before coming to this community (only for new admints)
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)
While you are in this community?
Should interview for Daily and Activity preferences be conducted?
Yes
No
Not Assessed
How Important is it to you to choose what clothes to wear?
Very
Somewhat
Not very
Not Important
No Response
Not Assessed
How important is it to you to take care of your personal belongings or things?
Very
Somewhat
Not very
Not Important
No Response
Not Assessed
How important is it to you to choose between a tub bath, shower, bed bath or sponge bath?
Very
Somewhat
Not very
Not Important
No Response
Not Assessed
How important is it to you to have snacks available between meals?
Very
Somewhat
Not very
Not Important
No Response
Not Assessed
How important is it to you to choose your own bedtime?
Very
Somewhat
Not very
Not Important
No Response
Not Assessed
How important is it to you to have your family or a close friend involved in discussion about your care?
Very
Somewhat
Not very
Not Important
No Response
Not Assessed
How important is it to you to be able to use a phone in private?
How important is it to you to have a lock your things to keep them safe?
How important is it to you to have books, newspaper and magazines to read?
Very
Somewhat
Not very
Not Important
No Response
Not Assessed
How important is it to you to listen to music you like?
Very
Somewhat
Not very
Not Important
No Response
Not Assessed
How important is it to you to be around animals such as pets?
Very
Somewhat
Not very
Not Important
No Response
Not Assessed
How important is it to you to listen to music you like?
Very
Somewhat
Not very
Not Important
No Response
Not Assessed
How important is it to you to keep up with the news?
Very
Somewhat
Not very
Not Important
No Response
Not Assessed
How important is it to you to do things with groups of people?
Very
Somewhat
Not very
Not Important
No Response
Not Assessed
How important is it to you to do your favorite activities?
Very
Somewhat
Not very
Not Important
No Response
Not Assessed
How important is it to you to go outside to get fresh air when the weather is good?
Very
Somewhat
Not very
Not Important
No Response
Not Assessed
How important is it to you to participate in religious services or practices?
Very
Somewhat
Not very
Not Important
No Response
Not Assessed
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
Choosing clothes to wear
Yes
No
Caring for personal belongings
Yes
No
Receiving bed bath
Yes
No
Receiving sponge bath
Yes
No
Snacks between meals
Yes
No
Staying up past 8PM
Yes
No
Family or Signicant other involvment in care discussions
Yes
No
Use of phone in private
Yes
No
Place to lock personal belongings
Yes
No
Reading books, newspaper or magazines
Yes
No
Listening to music
Yes
No
Being around animals such as pets
Yes
No
Keeping up with the news
Yes
No
Doing things with groups of people
Yes
No
Participating in favorite activities
Yes
No
Spending time away from nursing home
Yes
No
Spending time outdoors
Yes
No
Participating in religious activities
Yes
No
Non of the above
Yes
No
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
Resident Care Plan
Allergies
DOB
Admission Date
Physcian
Room
Focus
Goal
Interventions
FREQ/RESOLVED
Focus
Goal
Interventions
Freq/Resolved
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
CARE PLAN HISTORY
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Status
StatusDate
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Discharged
Passed
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