* = Required Information
Male Female
Patient will be free from injury Patient will receive assistance with ADLs/IADLs Other
(Check appropriate interventions, write specifics as needed)
Type of Diet Plan/Prepare Meals/Snacks Serve Meals Assist with Eating
Offer Fluids Fluid Restriction Thicken Fluids
Body Mechanics/Mobility
Assist Stand/Pivot Sliding Board
Bed rest Hoyer
Assist Cane Wheelchair Walker
Crutches ROM/HEP Apply Orthopedic Device Other
Personal Care/Assistance with ADLs
Tub Shower Bed Chair
Shower Bench Hand Held Shower Other
Comb/Brush Shampoo Condition
Dress Shave Skin Care/ Grooming
Clean Dentures Brush Teeth Mouthwash Oral Swabs
Assist to Commode / Toilet Assist with Bedpan / Urinal Catheter Care
Empty Catheter / Draining Bag Diapers / Depends Other
Shop Straighten Clean bathroom after use
Clean Kitchen after Meal Preparation Make Bed Change Bed Linen
Personal Laundry Medication Reminder Assistance Other
Temp A/O Intake/Output Pulse
B/P Respiration Observe Universal Precautions
Call office immediately for any fall, loss of consciousness, injury, oral temp above , pulse above or below