AFL Care Plan - Initial Assessment
*Did you collect a signed arbitration agreement in the direct care provider's preferred language?
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Yes
No
Other
Participant Information
Participant Name
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First and Last Name
Participant's Address
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Street Address
Apt or Unit #
City
State / Province
Postal / Zip Code
Primary Language
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Date of Birth
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Month
/
Day
Year
Date
Gender:
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Male
Female
Start of Service
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Month
/
Day
Year
Date
Type of Assessment
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Please Select
Initial Assessment
Change in Level of Care
Change in Health Status
Return to Community after Extended Hospital or Nursing Home Stay
Contact Information
Direct Care Provider
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Caregiver Phone Number
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Alternate Direct Care Provider
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Emerest must have 2 caregivers listed for the client
Alternate Caregiver Phone Number
*
Please enter a valid phone number.
RN/LPN Name
*
Nurse's Phone Number
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Please enter a valid phone number.
Primary Physician
Primary Physician Phone Number
Please enter a valid phone number.
Other Contact
Other Phone Number
Please enter a valid phone number.
Care Plan
Primary Diagnosis
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Important Medical Considerations
Secondary Diagnosis
Cultural Considerations
Care Plan Strategies
Daily Living Activity
Positioning in bed - Help Needed:
Independent
Setup
Cueing/Supervision
Phys. Assist
Dependent
Positioning in bed - Equipment Used:
Bed Pillow
Hospital Bed
Trapeze
Life Systems
Comments/Preferences/Special Instructions
Care Plan Strategies
Moving- transferring to/from bed, car
Moving- transferring to/from bed, car, chair etc. - Help Needed:
Independent
Setup
Cueing/Supervision
Phys. Assist
Dependent
Moving- transferring to/from bed, car- Equipment Used:
Transfer Board
Gait belt
Hoyer Lift
Walker/Cane nearby
Comments/Preferences/Special Instructions
Care Plan Strategies
Walking/Ambulation
Walking/ Ambulation -Help Needed- INDOOR
Independent
Setup
Cueing/Supervision
Phys. Assist
Dependent
Walking/ Ambulation - Help Needed-OUTDOOR
Independent
Setup
Cueing/Supervision
Phys. Assist
Dependent
Walking/ Ambulation-Equipment Used
Cane in home
Cane out of home
Walker in home
Walker out of home
Wheelchair
Power Wheelchair
Comments/Preferences/Special Instructions
Care Plan Strategies
Getting Dressed
Getting Dressed-Help Needed - UPPER BODY
Independent
Setup
Cueing/Supervision
Phys. Assist
Dependent
Getting Dressed-Help Needed - LOWER BODY
Independent
Setup
Cueing/Supervision
Phys. Assist
Dependent
Getting Dressed-Equipment Used
Picks out own clothes
Needs help picking
No buttons/zippers
Pullovers/ups/on
Put clothes within reach
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Daily Living Activity
Eating & Drinking- Help Needed
Independent
Setup
Cueing/Supervision
Phys. Assist
Dependent
Eating & Drinking-Equipment Used
Nutrionally balanced meals
Special diet needs
Special diet preferences
Special consistency
Feeding tube
Encourage drinking fluids
Fluid restrictions
Choking prevention plan
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Using the toilet
Using the toilet- Help Needed
Independent
Setup
Cueing/Supervision
Phys. Assist
Dependent
Using the toilet- Particpant has
Bowel Incontinence/Accidents
Urinary Incontinence/Accidents
Using the toilet - Equipment Used
Dependent Ostomy
Catheter
Personal catheter care
Raised toilet seat
Bedside commode
Supplies (e.g. diapers)
Needs reminders
Toilet schedule (describe)
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Bathing/ Showering
Bathing/ Showering- Help Needed
Independent
Setup
Cueing/Supervision
Phys. Assist
Dependent
Bathing/ Showering- Equipment Used
Hand-held shower
Shower chair
Transfer bench
Grab bars
Non-skid mat
Bed/sponge bath
Prefers to wash at sink
Prefers bed bath
Bath/shower assist by...
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Washing up, brushing teeth, hair
Washing up, brushing teeth, hair- Help Needed
Independent
Setup
Cueing/Supervision
Phys. Assist
Dependent
Washing up, brushing teeth, hair- Equipment Used
Needs Reminders
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Preparing meals
Preparing meals- Help Needed
Independent
Some help
Full help
Performed by others
Preparing Meals-Equipment Used
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Doing light housework
Doing light housework- Help Needed
Independent
Some help
Full help
Performed by others
Doing light housework - Equipment Used
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Transportation
Transportation- Help Needed
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Independent
Some help
Full help
Performed by others
Transportation- Equipment Used
*
Needs wheelchair van
Uses a ride service
DCP/Family transports
Comments/Preferences/Special Instructions
You selected that the CG/Family transports the client. Did you collect their Driver's License and Car Insurance Information?
*
Yes
No
Care Plan Strategies Cont.
Finances
Finances- Help Needed
Independent
Some help
Full help
Performed by others
Finances - Equipment Used
Power of Attorney
Conservator
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Phone Use
Phone Use- Help Needed
Independent
Some help
Full help
Performed by others
Phone Use- Equipment Used
TTY/Relay/Other
Has access
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Shopping
Shopping- Help Needed
Independent
Some help
Full help
Performed by others
Shopping - Equipment Used
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Other-Fall, Risks, and Safety
Fall, Risks, and Safety- Help Needed
High risk for falling
High risk for injury if fall
Fall, Risks, and Safety- Equipment Used
Walker
Cane
Hip protector
Other...
Fall, Risks, and Safety- Equipment Used
Report all falls/near fall
Report any changes in balance
Remind to use cane/walker
Remind to use safe shoes
Remind to wear glasses
Remind to wear hearing aid
Remind to call PCP if dizzy/lightheaded
Get up/change position slowly
Night light at night
Keep pathways and stairs clear + well lit
No slippery surfaces or throw rugs
Other
Comments/Preferences/Special Instructions
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Care Plan Strategies Cont.
Other-Medication Preparation/Organization
Medication Preparation/Organization- Help Needed
Independent
Some help
Full help
Performed by others
Medication Preparation/Organization- Equipment Used
Pill Box set up by...
Lockbox managed by...
Pharm pre-filled pack
Sharps container
Automatic pharmacy delivery
Automatic delivery by mail
Pick up medicine
Notify doctor if difficulty taking med.
Notify doctor of any side effects
Report changes in med. to agency
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Sensory and Communication-Vision
Vision- Performance
Good
Fair
Poor
Blind (or legally blind)
Vision- Equipment Used
Wears glasses/contacts
Magnifying glass
Reads braille
Other...
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Sensory and Communication-Hearing
Hearing- Performance
Good
Fair
Poor
Deaf
Hearing- Equipment Used-Wears hearing aid:
No
Left
Right
Both
Hearing- Equipment Used-Wears hearing aid:
Uses Sign Language
Reads lips
Uses adaptive devices...
Other...
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Sensory and Communication-Communication
Communication- Performance
Uses spoken language
Non-verbal: makes needs known by....
Communication- Equipment Used
Communication board
Sign Language
Device/App...
Other...
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Sensory and Communication-Pain
Pain- Performance-Pain Frequency
No Pain
Less than daily
Daily (once)
Daily (multiple)
Pain- Performance-Usual Pain Level (Self-Report)
None
Mild
Moderate
Severe
Excruciating
Pain- Performance-Pain Control is:
Good
Fair
Poor
Pain- Performance-Pain - Other:
Pain interferes with activities
Pain location (specify in comments)
Pain source (specify in comments)
Pain triggered by (specify in comments)
Pain- Equipment Used
Uses pain clinic...
Uses equipment to help with pain management (e.g. TNS, braces)
Takes medication for pain (describe pattern, control)
Uses herbal treatment for pain
Uses relaxation (meditation, imagery, etc.) for pain
Alternative therapy (yoga, massage, acupuncture, chiropractor)
Exercise/physical therapy
Other...
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Nutrition Status-Meal Intake
Meal Intake- Performance
Excellent
Very Good
Fair
Poor
None
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Nutrition Status-Output
Output- Performance
Excellent
Very Good
Fair
Poor
None
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Cognitive Status
Cognitive Status
Alert
Oriented
Confused
Some Confusion
Non-Alert or Oriented
Cognitive Status-Alert, Oriented, Confused, Some Confusion, Non-Alert or Oriented- Performance
Alert & Oriented x3
Alert & Oriented to Self and Place
Alert to Self Only
Non-Alert or Oriented
Comments/Preferences/Special Instructions
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Care Plan Strategies Cont.
Health Conditions / Behavioral Situations that Require Extra Attention
Health Conditions / Behavioral Situations that Require Extra Attention
*
Who Manages?
*
Participant
DCP
Both
Other...
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Health Conditions / Behavioral Situations that Require Extra Attention
Health Conditions / Behavioral Situations that Require Extra Attention
Who Manages?
Participant
DCP
Both
Other...
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Health Conditions / Behavioral Situations that Require Extra Attention
Health Conditions / Behavioral Situations that Require Extra Attention
Who Manages?
Participant
DCP
Both
Other...
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Medical Treatments and Equipment-Tratments
Treatments-Services, Equipment, etc.
Dialysis
Radiation/Chemotherapy
Wound care by...
Injections by...
Other...
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Medical Treatments and Equipment-Equipment Management
Equipment Management-Services, Equipment, etc.
Oxygen
CPAP
Nebulizer
IV pump
Needles/syringes
Feeding tube pump
Feeding tube supplies
Catheter supplies
Ostomy supplies
Other...
Cares for equipment as directed:
Yes
No
Care provided by....
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Home & Community Program(s) and Services
Home & Community Program(s) and Services -Services, Equipment, etc.
Home Health services (specify)
Hospice (specify)
Visiting Nurse
Physical Therapy:
Occupational Therapy:
Home Visiting Doctor/Nurse Practioner
Companion, Private Pay help
Home Delivered Meals
Transportation
Adult Day Health
Mental Health Counselor
Other
Physical Therapy
*
Home
Outpatient
Occupational Therapy:
*
Home
Outpatient
Comments/Preferences/Special Instructions
Care Plan Strategies Cont.
Home & Environment Checklist
Emergency Planning-Service Details
*
Clean and in good repair and is regularly maintained
Acceptable Lighting, heating, cooling and ventilation
Conforms to applicable building, health & safety codes.
Provides adequate privacy for the participants.
Equipped with a fire extinguisher and first aid kit.
Free of Clutter
Other
Other
Comments/Preferences/Special Instructions
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Special Instructions & Additional Comments:
*
Provide a brief and detailed summary of your findings. Include information regarding the caregiver's ability to care for the client.
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*
I have confirmed that the participant and the Direct Care Provider reside in the same home (Please be sure to collect a proof of address)
.
*
This plan was reviewed with participant and Direct Care Provider
Participant Signature
*
Date
*
/
Month
/
Day
Year
Date
Direct Care Provider Signature
*
Date
*
/
Month
/
Day
Year
Date
RN/LPN Signature
*
Date
*
/
Month
/
Day
Year
Date
RN Email
*
example@emerest.com
Direct Care Provider's Email
*
They will receive a copy of this assessment
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