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Sample Senior Care Plan

Client: Jane Doe Client#: 2000

Address: 100 W. Main Street, #501, Chicago, IL 60606

Directions: (Include directions for driving by car or traveling by public transportation including bus numbers).

Caregiver Staffing Requirements: Caregiver must have driver’s license to run errands

Telephone Number: 000-000-0000

Emergency Contact Information

Medical Emergency: 9-1-1

(Always call 9-1-1 first if there is an urgent medical condition).

Doctor: Name, Address, Phone

Pharmacy: Osco Drug PH: 000-000-0000

(Does Pharmacy Deliver? If not, suggest one that does)

Lifeline Necklace: 800-000-0000

Medicare Covered Physical Therapy: Mon, Wed, Fri, from 2pm – 4pm

Family Contacts:

1) Neighbor: Joan Smith, PH: 312-000-0000

2) Son: John Doe, PH: 312-000-0000

Care Service Arrangements

Service Plan:

❑ Monday: 9:30AM – 12:30PM

❑ Tuesday: 9:30AM – 12:30PM

❑ Wednesday: 9:30AM – 12:30PM

❑ Thursday: 9:30AM – 12:30PM

❑ Friday: 9:30AM – 12:30PM

❑ Saturday: 9:30AM – 12:30PM (When requested)

❑ Sunday: 9:30AM – 12:30PM (When requested)

Note: Family usually stops by on weekends but if they are unable to do so, may request a Caregiver.

Services to be Performed:

❑ Monitor medication schedule

❑ Assist with meal planning and preparation

❑ Monitor morning shower and assist with dressing

❑ Assist with physical therapy routine

❑ Maintain clean household: clean bathroom, kitchen, vacuum, dust, help water plants, take out garbage

❑ Engage in conversation and mental stimulation (likes daily crossword puzzle in newspaper)

❑ Escort to Beauty Salon on Friday morning

❑ Laundry in basement: change and launder bed linens

❑ Maintain updated calendar (Children will escort to doctor’s appointments approximately every two weeks)

Meals: Encourage nutritious eating and low sodium intake

Breakfast: Instant Carnation breakfast

Lunch: Soup or grilled cheese sandwich (something light)

Dinner: Prepare main course entrée for reheating later

Personal Profile

Name: Jane Doe Age: 83 Birthday: 2/15/1926

Height: 5’3” Weight: 115 lbs.

Medical Conditions: Fibromyalgia, Thyroid condition, Spinal Stinosis (treated with steroids), blood pressure erratic which has caused some dizziness. Blood pressure is the most serious medical condition currently and blood count was found to be too low and received 3 blood transfusions during recent hospitalization. Received new medications to monitor blood pressure and doctor wants to monitor effectiveness of these medications.

Activities of Daily Living: Eyeglasses to read, Upper Dentures, walks without assistance, monitoring only for bathing, motivate/monitor exercises

Goals:

❑ Take medications as scheduled

❑ Healthy and nutritious eating

❑ Exercise: follow prescribed physical therapy routine

Interests:

❑ Enjoys playing golf at Country Club

❑ Enjoys knitting and indoor/outdoor flower garden

❑ 1 son: John, lives in New York

❑ 3 grandchildren

❑ 2 great grandchildren

❑ Worked as Administrative Assistant

❑ Enjoys friendships with life-long girlfriends living on the same street

Monitor Medications: Cousin is R.N. and fills pillboxes for two-weeks.[pic]

|Medication |Dosage |Time |Frequency |Treatment For: |

| | | | | |

|Restoril (Temazepam) |15mg |Bedtime |1x Daily |Sleeping Aide |

| | | | | |

|Effexor XR |150mg |Daily: AM |1x Daily |Depression |

| | | | | |

|Fergon |325mg |2x Daily: AM, PM |2x Daily |Iron Tablet |

| | | | | |

|Pepcid |20mg |2x Daily: AM, PM |2x Daily |Stomach Nausea |

| | |(As needed) | | |

| | | | | |

|Miacolm Nasal Spray |1 Spray |Daily: 1X |1x Daily |Bones/Osteoporosis |

| | | | | |

|Reglan |5mg |With meals and at bedtime |With meals |Constipation/Nausea |

| | | | | |

|Klonopin |1mg |Bedtime |1x Daily |Sleep/Anxiety |

| | | | | |

|Buspar |15mg |Daily: AM, Noon, PM |3x Daily |Restless Legs |

| | | | | |

|Cozaar |5mg |Daily |1x Daily |Blood Pressure |

| | | | | |

|Synthroid |75mg |Daily |1x Daily |Thyroid |

| | | | | |

|Amoxycillin |500mg |2x Daily: AM, Noon |3x Daily |Bladder Infection |

| | | | | |

|Provigel |50mg |Daily: AM |1x Daily |Fatigue |

| | | | | |

|Vetrom |50mg |3x Daily: AM, Noon, PM, As Needed |3x Daily |Pain: As needed |

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