HHA Care Plan/ and Progress Note Healthwatch Professionals

HHA Care Plan/ and Progress Note HealthWatch Professionals

Patient Name: Phone #:
Address: Alternate Phone #:
Case Manager/Nurse:
Frequency / Duration: Aide Visits:
Patient Diagnosis/Problems:
Goals for care: effective and safe personal care Patient clean comfortable other : / Parameters to notify Nurse:
Temp:
BP:
Pulse: Resp:
Urine:
Other:
Notify RN if care is refused
SAFETY AND OTHER PERTINENT INFORMATION – Check All That Apply (RN to review and revise at least every 60 days)
Lives Alone Lives with other
Bed bound Up as tolerated
Amputee (specify)
Vision problem: Glasses Contacts
Hard of Hearing Hearing aid
Other: / Dentures Upper Lower Partial
Oriented Alert Forgetful Confused
Urinary catheter Ostomy
Artificial limb (specify)
Diet
Food Allergies / Environment
Inadequate plumbing Inadequate heat / cooling
Inadequate refrigeration
Pest/rodent infested
Presence of animals
Supplies:
Activities Ordered By RN
**must have specific education/instructions / Frequency / Home Health Aide (√ ) Services Provided / Week of: //
Sunday / Monday / Tuesday / Wed / Thursday / Friday / Saturday
(QV = Every Visit CC = Client Choice A = Assist) / Time In
Time Out
PATIENT INITIALS / EACH VISIT
Bath: Bed Shower Tub Chair / QV CC A
Hair care/comb/brush / QV CC A
Shampoo / QV CC A
Catheter care Empty Catheter bag
Record I/O Date of last BM / QV CC A
Oral hygiene Brush Swab Dentures / QV CC A
Ambulation Assist W/C W/A Cane / QV CC A
Mobility/Transfer Assist: Chair Bed
Dangle Commode Shower/Tub / QV CC A
Skin Care Foot care Back Rub Shave
Deodorant Nails: Clean/File / QV CC A
Assist with Dressing / QV CC A
Assist with exercises ** / QV CC A
Assist with feeding / QV CC A
Meal preparation Diet: / QV CC A
Fluids: Limit Encourage / QV CC A
Change Wash linens Make bed / QV CC A
Clean: Bathroom Kitchen / QV CC A
Tidy Room / QV CC A
Safety Check Universal Precautions / QV CC A
Other: / QV CC A
Vital Signs __Date ______BP____T___P____R____Wt. / QV CC A
HOME HEALTH AIDE INITIALS / EACH VISIT

RN Signature: ______Date: Cert. Date: Initial Recertification Other

Home Health Aide Signature: ______Patient Signature: ______