Care Manager Name
Please Select
Diana Ross
Dwight Schrute
Shania Twain
Stevie Nicks
Forrest Gump
Care Manager Email
example@example.com
Care Manager Phone
Best number for Care Partner to reach you
Attending Clinician/s
Patient Name
Patient DOB
-
Month
-
Day
Year
Date
Primary Contact
Primary Contact Relationship
Plan of Care Created Date
/
Month
/
Day
Year
Date
Functional Status
Independent
Requires Assistance
Dependent
Notes
Bathing
Eating & Drinking
Dressing
Toileting
Sleeping
Oral Care
Medications
Exercise
Recreation & Activity
Identified Stressors & Behaviors
Please select a Goal & Proposed Intervention for each symptom / behavior
Anger / Agitation
Please Select
N/A - Monitor for changes
Reduce frequency of behavior
Manage Care Partner stress
Implement / improve redirection strategies
Minimize conflict
Seek additional care / treatment
Proposed Intervention
Send Lesson
Family Manual
Activity
Redirection Strategy
N/A
Other (Please Indicate)
hold CTRL button to select all that apply
Other Intervention
Please enter details
Hallucinations / Paranoia
Please Select
N/A - Monitor for changes
Reduce frequency of behavior
Manage Care Partner stress
Implement / improve redirection strategies
Minimize conflict
Seek additional care / treatment
Proposed Intervention
Send Lesson
Family Manual
Activity
Redirection Strategy
N/A
Other (Please Indicate)
hold CTRL button to select all that apply
Other Intervention
Please enter details
Sexually Inappropriate Behaviors
Please Select
N/A - Monitor for changes
Reduce frequency of behavior
Manage Care Partner stress
Implement / improve redirection strategies
Minimize conflict
Seek additional care / treatment
Other (Please Indicate)
Proposed Intervention
Send Lesson
Family Manual
Activity
Redirection Strategy
N/A
Other (Please Indicate)
hold CTRL button to select all that apply
Other Intervention
Please enter details
Repetitive Behaviors
Please Select
N/A - Monitor for changes
Reduce frequency of behavior
Manage Care Partner stress
Implement / improve redirection strategies
Minimize conflict
Seek additional care / treatment
Proposed Intervention
Send Lesson
Family Manual
Activity
Redirection Strategy
N/A
Other (Please Indicate)
hold CTRL button to select all that apply
Other Intervention
Please enter details
Wandering / Wanting to go home
Please Select
N/A - Monitor for changes
Reduce frequency of behavior
Manage Care Partner stress
Implement / improve redirection strategies
Minimize conflict
Seek additional care / treatment
Proposed Intervention
Send Lesson
Family Manual
Activity
Redirection Strategy
N/A
Other (Please Indicate)
hold CTRL button to select all that apply
Other Intervention
Please enter details
Wanting Mother
Please Select
N/A - Monitor for changes
Reduce frequency of behavior
Manage Care Partner stress
Implement / improve redirection strategies
Minimize conflict
Seek additional care / treatment
Proposed Intervention
Send Lesson
Family Manual
Activity
Redirection Strategy
N/A
Other (Please Indicate)
hold CTRL button to select all that apply
Other Intervention
Please enter details
Refusing Help
Please Select
N/A - Monitor for changes
Reduce frequency of behavior
Manage Care Partner stress
Implement / improve redirection strategies
Minimize conflict
Seek additional care / treatment
Proposed Intervention
Send Lesson
Family Manual
Activity
Redirection Strategy
N/A
Other (Please Indicate)
hold CTRL button to select all that apply
Other Intervention
Please enter details
Accusatory Behavior
Please Select
N/A - Monitor for changes
Reduce frequency of behavior
Manage Care Partner stress
Implement / improve redirection strategies
Minimize conflict
Seek additional care / treatment
Proposed Intervention
Send Lesson
Family Manual
Activity
Redirection Strategy
N/A
Other (Please Indicate)
hold CTRL button to select all that apply
Other Intervention
Please enter details
Getting to Appointments
Please Select
N/A - Monitor for changes
Reduce frequency of behavior
Manage Care Partner stress
Implement / improve redirection strategies
Minimize conflict
Seek additional care / treatment
Proposed Intervention
Send Lesson
Family Manual
Activity
Redirection Strategy
N/A
Other (Please Indicate)
hold CTRL button to select all that apply
Other Intervention
Please enter details
Recognition of Family Members
Please Select
N/A - Monitor for changes
Reduce frequency of behavior
Manage Care Partner stress
Implement / improve redirection strategies
Minimize conflict
Seek additional care / treatment
Proposed Intervention
Send Lesson
Family Manual
Activity
Redirection Strategy
N/A
Other (Please Indicate)
hold CTRL button to select all that apply
Other Intervention
Please enter details
Other Stressor Identified (please indicate)
Proposed Intervention
Send Lesson
Family Manual
Activity
Redirection Strategy
N/A
Other (Please Indicate)
hold CTRL button to select all that apply
Other Intervention
Please enter details
Cognitive Plan of Care
(Add any additional identified
stressors here)
Dementia Severity Rating
Patient PHQ 2
Care Partner PHQ 2
Cognition / AD8 Indicated Changes
Please Select
Yes
No
Did Not Answer
Targeted Micro Lessons Sent
Anger & Agitation
Accusatory Behavior
Bathing
Dressing
Eating & Drinking
Hallucinations & Paranoia
Health Conditions
Incontinence
Oral Care
Recognition Lost
Refusing Help
Repetitive Actions
Sexually Inappropriate Behavior
Wandering
Wanting to go home
Wanting Mother
AlzBetter Family Manual
Please Select
eManual Link Provided
Shipped
Given in person
PT/OT/ST Referral
Indicate any agencies already working with patient and/or make suggestion
Other Agency Referral
Indicate any agencies already working with patient and/or make suggestion
Additional Resources
Indicate any agencies already working with patient and/or make suggestion
To be reviewed with
Primary Care Partner Name
Relationship
Anticipated Date of Review
/
Month
/
Day
Year
Date
Coach Signature
Date
/
Month
/
Day
Year
Date
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