Information to have ready: Advance Directives. Idea of a Care Schedule. List of Medications and Allergies and Diet. Emergency Contact Sheet

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Randall O’Connor’
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1 Step by Step Care Guide Information to have ready: 1 Advance Directives 2 Idea of a Care Schedule 3 List of Medications and Allergies and Diet 4 Emergency Contact Sheet 5 Other Personal Information

2 Step by Step Care guide What is the Step by Step Care Guide? When a family member is in need of assistance, we understand the stress that comes with gathering the appropriate information to meet with home care providers. The Step by Step Care Guide is a way to have the right information ready when meeting with our agency, to save you time and stress. How do I use Help Us Help You? Before scheduling an in-home assessment with one of our care specialists, download this document and start gathering the information suggested. Use our simple checklist below to check off information collected. CHECKLIST: Advanced Directives: Living Will, Do Not Resituate Order Medications List: Including allergies Special Diet List Emergency Contact List Other Personal Information List: Insurance contact person if using a long term policy

3 In the initial assessment we will ask you if you have any advance directives, living will, or D.N.R. (Do not resuscitate order) Any of these documents need to be placed in an envelope and taped onto the refrigerator of the residence where care is being given. This is so in case of an emergency, the emergency responder knows where to find such directions. What is an advanced directive : An advanced directive is a set of directions you give about the health/mental health care you want if you ever lose the ability to make decisions for yourself. North Carolina has three ways for you to make a formal advanced directive. One way is called a living will ; another is called a health care power of attorney ; and another is called an advance instruction for mental health treatment. Do I need to have an advanced directive and what happens if I don t? Making a living will, a health care power of attorney or an advanced instruction for mental health treatment is your choice. If you become unable to make your own decisions; and you have no living will, advance instruction for mental health treatment, or a person named to make medical/mental health decisions for you ( health care agent ), your doctor or health/mental health care provider will consult with someone close to you about your care. What is a living will? In North Carolina, a living will is a legal document that tells others you want to die a natural death if you: - become incurably sick with an irreversible condition, that will result in your death within a short period of time; - are unconscious and your physician determines it is highly unlikely you will regain consciousness; or - have advanced dementia or a similar condition which results in a substantial cognitive loss and it is highly unlikely the condition can be reversed. Advanced d directives

4 My loved one: Getting out of bed: Needs someone to shadow them as they get out of bed Needs someone to help them stand Needs someone to physically move them into a mobility device Other:_ Going to the bathroom: Needs someone to shadow them as they walk to the bathroom, and use the facility Needs someone to help them transfer from a mobility device to the toilet Needs someone to help them wipe/clean up after using the bathroom Needs someone to hands-on assisting with toileting because they are incontinent Needs someone to empty elimination bags Other: Taking a Bath/Shower: Needs someone to shadow them as they get into the bath/shower and use the facility Needs someone to help them transfer from a mobility device into the bath/shower Needs someone to help them bathe in bath/shower Needs someone to give them bed bath because they are unable to move from bed Needs someone to assist with shaving Other: Getting dressed: Needs someone to help them pick out their outfits for the day/week Needs someone to hand them their clothing and supervise as they dress themselves Needs someone to lightly assist them as they dress themselves Needs someone to full on dress them, buttoning up the garments and lifting them as they dress the client Other: Brushing their teeth: Needs someone to shadow them as they brush their own teeth Needs someone to help them reach their toiletries and they can brush their own teeth themselves Needs someone to brush their teeth for them Care Plan ideas Doing their hair: Needs someone to shadow them as they do their own hair Needs someone to hand them their brush and appliances as they do their own hair Needs someone to physically brush and style their hair for them Other: Medication Reminders: Needs someone to remind me to take my medicine Needs someone to get me a drink and/or snack and remind me to take my medicine Other:_

5 My loved one: Preparing Meals: Needs someone to help them meal plan for the week Needs someone to cook them meals and freeze them for the week Needs someone to heat up a frozen dinner for the client Needs someone to shadow them as they cook themselves a meal Needs someone to cook with them Needs someone to prepare the them a light: (circle one) BREAKFAST SNACK LUNCH DINNER Needs someone to monitor and use guided maneuvering to help them eat Needs someone to feed them Transportation: Needs someone to take them to church, local activities, social gatherings etc Needs someone to take them to the mall, the park, shopping etc Needs someone to take them to the grocery store and help me pick out items Needs someone to take them to the doctors office and wait for me in the waiting room Needs someone to take them to the doctors office and take notes Needs someone run errands for them with client permission Other: Light Housekeeping: Needs someone to clean the kitchen and bathroom after usages Needs someone to vacuum and mop floors Needs someone to change linens and make the bed Needs someone to do light dusting and clean mirrors and countertops Needs someone to do laundry (frequency) Other: Companionship: Needs someone to keep them company and converse with Needs someone to play board games, look at pictures, play cards, and encourage social interaction Needs someone encourage them to go for walks, be physically active Needs someone to just sit and make sure that the client doesn t get out of bed at night Needs someone to sit and make sure they are comfortable and has everything that one needs Read to them Read a daily devotion to them Other: Care Plan ideas Other Activities: Needs someone to remind them to take their own Blood Pressure Freq Needs someone to remind them to take their blood sugar/glucose levels Needs someone to take their Blood Pressure for them and record results Freq Needs someone to record fluid intake and outtake

6 Hourly Daily Schedule: Date: Circle One: M T W Th F St Sn Time: Activity: Notes: 6am 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm Care Plan ideas 8pm 9pm 10pm 11pm 12am *By filling out what a typical day is like, we get an understanding of the client s regular schedule to ensure it stays consistent

7 Medications List Medications for: Allergies: *Use alternative side if all space is used

8 Space provided below is to write in meals typically eaten by client on a weekly basis Breakfast Lunch Dinner Snacks Bread/Grains bread bagels pasta tortillas buns Breakfast cereal oatmeal baking mix Meat bacon chicken fish ground beef hot dogs sausage Drinks coffee tea juice milk water Condiments catsup mayonnaise mustard oil salad dressing spices Sun Mon Tues Weds Thurs Friday Sat Fruits/Veggies apples avocado bananas berries beans broccoli cauliflower celery cucumber garlic grapefruit grapes kiwi lettuce mushrooms onions oranges peaches peas spinach sprouts squash Tomato Snacks chips cookies candy nuts/seeds Basic Grocery List butter cheese eggs sour cream Yogurt Frozen meat pizza TV dinners ice cream waffles vegetables Cans/Jars fruit/vegetables jam/jelly peanut butter soup chili Sp pecial Diet

9 Emergency Contact Sheet: Client s Name: Client s Address: Primary Physician Name: Primary Physician's Phone Number: Primary Physician s Address: Nearest Hospital (Name and Address): Emergency Contact: (Name and Number): Emergency Contact: (Name and Number): Emergenc cy contacts

10 Client s Full Name: Client s D.O.B. Marital Status Please check any known medical problems that you have at present: Diabetes Heart Trouble Alzheimer s Alcoholism High Blood Pressure Easy Bleeding Dementia Parkinson s Arthritis Asthma High Blood Fats Tuberculosis Stroke Psychiatric Illness Cancer of Thyroid Problems Other: Please list and other pertinent medical/surgical history (including surgical procedures with dates): Does the client have a driver s license? Does the client want the caregiver to transport them in the caregiver s car? YES NO Does the client want the caregiver to transport them in the client s car? YES NO If yes: Does the client have up to date car insurance? YES NO Please list provider and policy number: (This is information that will be needed for the transportation waiver) Are you going to be using a long-term care insurance policy? YES NO If yes, please list the account representative that will be handling the case Name: Phone: Fax: Personal in nformation

PEAK 2.0 SAMPLE ACTION PLAN FOOD ACTION PLAN

PEAK 2.0 SAMPLE ACTION PLAN FOOD ACTION PLAN Facility Name: Example 5 Nursing Home Domain: #1 Resident Choice Core: #1 Food ACTION PLAN Provider Number: Action Plan Contact: Phone number and/or e-mail: WHAT HAS BEEN WORKED ON IN THIS CORE AREA SINCE