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| About site: Disabled/Respite Care - Respite Care Checklist |
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| About site: http://www.efmoody.com/longterm/respitechecklist.html |
Title: Disabled/Respite Care - Respite Care Checklist Client information form for respite caregivers.
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Hungary Hungarian Ministry of Defence, also known as the Honvédelmi Minisztérium.
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| Respite ChecklistRESPITE CAREGIVERCHECKLISTRespite care is when someone comes and gives the regular caregiver some "timeoff" from their duties (and is usually covered in some extent by most homehealth care policies). But that does not mean that the respite care caregiverhas complete knowledge of the patient nor knows the best way of treatingthem. Here is checklist developed by the Dini Alves who cared for her motherfor 15 years. She suggests that the caregivers be given this form along withbackup instructions for Universal Precautions, advanced directives, foodpreferences or any medical equipment in use. Print out and make your ownrevisions. But do use it- it can save a lot of time, questions and anxietyPatient _____________________ Social Security Number _____________ Birthdate_________Doctor______________________________ Phone __________ Location___________________Hospital___________________ Phone ______________ Medical Insurance______________Home/ Health/Hospice Patient?_______ Agency Phone_____________Nurse_______________Diagnoses________________________________________ How Long_________________Characteristics of diagnoses affecting care___________________________________________Current Symptoms ____________________________________________________________Allergies ____________________________________________History of seizures??_____Patient's general emotional state (shy, sense of humor, weepy, sudden outbursts,etc)___________________________________________________________________________ Generally understand instructions____ May not understand instructions_____ Vision LimitationsFavorite distractions/Likes______________________________________________________Dislikes_____________________________________________________________________Universal Precautions instructions can be found_____________________________________Vital Signs____Don't need to take. ______ Take every ____ Hours. ______ Record date,time and reading on separate sheet of paper____ Pulse _____ Blood Pressure ____ Respirations Temperature __under tongue__Other MEDICATIONS DOSE TIME TO BE GIVEN SPECIALS INSTRUCTIONS 1. __________________________________________________________________________2. __________________________________________________________________________3. __________________________________________________________________________Special InstructionsA. Give on Empty StomachB. Wake up patients to give MedicationsC. With food/liquid (circle)D. Give (time) before eatingE. Give on patient RequestF. Avoid ______________G. Document when givenH. Other _____________ Medical Equipment When Needs Assistance Need to Know 1. __________________________________________________________________________2. __________________________________________________________________________Appointments (doctor's office, physical therapy, beauty/barber, visit friends,ball game, etc.) To (Name) Location phone Date Time 1. __________________________________________________________________________2. __________________________________________________________________________PERSONAL CARE AND COMFORTPersonal Care needs (attach instructions to this sheet) Catheter Care Hearing aid Shaving Peri-Care Mouth/Oral care Bed Sores Foley Bag Dressings Changed Hair/skin/nail care Dentures Moving Patient Moves around unassisted Transfers from bed to chair with assistance Bedbound Reposition Requires Special life Special InstructionsWalking/transporting patients Unassisted Cane Walker Wheelchair Physical Therapies1. Unassisted2. Needs Assistance3. Range of Motion__________________________ Frequency ___________________4. Special Exercises ________________________________________Toileting Unassisted Bedpan Urinal Catheter Colostomy Bedside Commode Incontinent pads other Bathing Bed bath Shower Tub Needs assistance __times per week Equipment needed1. None2. Transfer bench3. Shower bench4. WheelchairBedroom Comfort Bedtime Wake time Nap time(s) Room temperature Closed windows Prefers room dark Change Bed Pull sheet Blankets(s) Day__ or night__ Special bed items (sheepskin, egg crate mattress, extra pillows- attach sheet)Food- for meals/snacks or special instructions, see attached list Needs Assistance feeding Needs to be fed Has difficulty swallowing Takes nothing by mouth Tube feeding Soft foods Record Liquid Intake Meal times___ Breakfast____Luch_____ Dinner_______SnackEntertainment Options/preferences TV Radio Reading or being read to cards Other Avoid_________________________________________________________HOUSE RULES AND INSTRUCTIONS 1. Locking Doors2. Don't Smoke3. Working Stove4. Fireplace5. Gas shut off valve6. Fire Extinguishers7. Guests8. Pet Care guidelines9. NeighborsOtherinformation________________________________________________________________________________________________________________________________________________________________________________________________________________________EMERGENCY PREPAREDNESSDiscuss 911preferences_____________________________________________________DNR Order or Advanced Directives can be found______________________________I'll return home on____________________I will be away from ________________________to________________________Location___________________________________________Phone__________________Friends and Relatives you can contact in an emergencyName/address_____________________________________________ Phone____________Name/address_____________________________________________ Phone____________ |
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Client | information | form | for | respite | caregivers. |
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http://www.efmoody.com/longterm/respitechecklist.html
Respite Care Checklist 2008 October
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Client information form for respite caregivers.
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