STATE of OREGON Page 1 of 4
STATE OF OREGON Page 1 of 4
DEPARTMENT OF HUMAN SERVICES
SENIORS AND PEOPLE WITH DISABILITIES Apr 17 2009
TASK LIST
Client Information
______
Name: Minnie Mouse
Address: XXXXXXXXXXXXX Assessment Date: 04/15/09
City and State: Medford OR Service Review Date: 04/30/10
Print Date: 04/17/09 Prime # XXXXXXXX
Worker: White, Snow
Worker Phone: 503-000-0000
______
Provider Name: Donald Duck Provider: XXXXXX
Address: XXXXXXXXXXXX
City and State: MEDFORD OR
Phone: 541-000-0000
______
Hours Authorized:
ADL: 145 IADL: 85 24-Hr Avail: 159 Total: 389
______
Tasks To Be Completed
Bowel
Changing incontinence supplies Digital stimulation
Ostomy care Toileting schedule
Suppository insertion Enemas
______
Lunch
Cutting food Placing food/utensils within reach
Lunch Preparation
______
Memory
Memory
______
Eating
Feeding or cueing during eating Monitoring to prevent choking
Assistance with special utensils Tube feeding
Nutritional IV set up
______
Bathing
Bathing and Washing Hair Getting in or out of shower or tub
______
Bladder
Changing incontinence supplies Catheter Care
STATE OF OREGON Page 2 of 4
DEPARTMENT OF HUMAN SERVICES
SENIORS AND PEOPLE WITH DISABILITIES Apr 17 2009
Mouse, Minnie SDS598N
TASK LIST (con’t)
Ostomy care Toileting schedule Monitoring for infection
______
Laundry
Gather and wash soiled clothing and linens Use washing machines / dryers
Hang/fold/put away clothes
______
Dressing
Assist with dressing/undressing
______
Grooming
Nail care(Toe/finger) Brushing/combing hair
______
Shopping
Food Clothing Medicine
Driving to/from and purchasing goods needed for health & safety related to the service plan
______
Judgment
Making decisions
______
Awareness
Help understanding basic health and safety needs
______
Wandering
Wandering
______
Breakfast
Cutting food Placing food/utensils within reach
Breakfast Preparation
______
Toileting
Getting to/from the toilet Assist with using bedpan Urinal Commode
Wiping/Cleansing afterward Cleaning assistive devices Adjusting clothing before/after
______
Transfers
Moving to or from a chair, bed or wheelchair inside the home
______
Ambulation
Assistance moving around inside home Assistance moving around outside
STATE OF OREGON Page 3 of 4
DEPARTMENT OF HUMAN SERVICES
SENIORS AND PEOPLE WITH DISABILITIES
Apr 17 2009
Mouse, Minnie SDS598N
TASK LIST (con’t)
Adaptation
Coping with change
______
Orientation
Help with confusion
______
Housekeeping
Wiping surfaces Cleaning floors
Making bed Taking out the garbage
Dusting Cleaning dishes
______
Transportation
Assisting during a ride Assist to get in/out of a vehicle Arranging a ride
______
Dinner / Supper
Cutting food Placing food/utensils within reach
Dinner/Supper Preparation
______
Personal Hygiene
Shaving Denture care Brushing teeth/caring for mouth
______
Demands on others
Responding to behaviors
______
24 Hour Availability
Meet needs during 24-hour period; includes night needs
______
Medication Management
Giving Medicines Giving oxygen Reminding/Organizing
Checking for effectAssuring adequate oxygen supply
______
Danger to Self or Others
Responding to behaviors Remarks/Special Instructions
STATE OF OREGON Page 4 of 4
DEPARTMENT OF HUMAN SERVICES
SENIORS AND PEOPLE WITH DISABILITIES Apr 17 2009
Mouse, Minnie SDS598N
TASK LIST (con’t)
Client Information
Name: Minnie Mouse
Address: XXXXXXXXX Date: 04/15/09
City and State: Medford OR Service Review Date: 04/30/10
Zipcode: 97504 Print Date: 04/17/09
Prime # XXXXXXXX Worker: White, Snow
Worker Phone: 503-000-0000
______
Authorizing Signature (Case Manager/UnitManager)Date
Signature Employer Date ______
Signature Homecare Worker Date ______
NOTE: Homecare Workers are not authorized to provide animal care (this includes service
animals) or yard work.
Mouse, Minnie SDS598N